Provider Demographics
NPI:1649607011
Name:WOOLLERY, MAGUALIE (DMD)
Entity type:Individual
Prefix:DR
First Name:MAGUALIE
Middle Name:
Last Name:WOOLLERY
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7760 HAMPTON PL
Mailing Address - Street 2:BUILDING 6
Mailing Address - City:LOGANVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30052-6770
Mailing Address - Country:US
Mailing Address - Phone:678-639-0080
Mailing Address - Fax:678-639-0088
Practice Address - Street 1:7760 HAMPTON PL
Practice Address - Street 2:BUILDING 6
Practice Address - City:LOGANVILLE
Practice Address - State:GA
Practice Address - Zip Code:30052-6770
Practice Address - Country:US
Practice Address - Phone:678-639-0080
Practice Address - Fax:678-639-0088
Is Sole Proprietor?:No
Enumeration Date:2013-10-01
Last Update Date:2013-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0121421223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA442081793BMedicaid