Provider Demographics
NPI:1174276026
Name:WALLS, SHANNON
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:WALLS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3255 11 AIRBORNE DIVISION ROAD
Mailing Address - Street 2:
Mailing Address - City:FORT BENNING
Mailing Address - State:GA
Mailing Address - Zip Code:31801
Mailing Address - Country:US
Mailing Address - Phone:706-544-9071
Mailing Address - Fax:
Practice Address - Street 1:3255 11 AIRBORNE DIVISION ROAD
Practice Address - Street 2:
Practice Address - City:FORT BENNING
Practice Address - State:GA
Practice Address - Zip Code:31801
Practice Address - Country:US
Practice Address - Phone:706-544-9071
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-01
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA125J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes125J00000XDental ProvidersDental Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA3346105139Medicaid