Provider Demographics
NPI:1972616878
Name:TREADWAY, ANTWAN LONDELL (DMD)
Entity Type:Individual
Prefix:
First Name:ANTWAN
Middle Name:LONDELL
Last Name:TREADWAY
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1790 MULKEY RD
Mailing Address - Street 2:SUITE 3A
Mailing Address - City:AUSTELL
Mailing Address - State:GA
Mailing Address - Zip Code:30106-1122
Mailing Address - Country:US
Mailing Address - Phone:770-941-2476
Mailing Address - Fax:770-941-5710
Practice Address - Street 1:1790 MULKEY RD
Practice Address - Street 2:SUITE 3A
Practice Address - City:AUSTELL
Practice Address - State:GA
Practice Address - Zip Code:30106-1122
Practice Address - Country:US
Practice Address - Phone:770-941-2476
Practice Address - Fax:770-941-5710
Is Sole Proprietor?:No
Enumeration Date:2006-08-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA122091223S0112X
FLDN137651223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000849439BMedicaid
GA000849439CMedicaid
GAU77950Medicare UPIN
GA000849439CMedicaid