Provider Demographics
NPI:1104311620
Name:FAULKNER, CAMERYN
Entity type:Individual
Prefix:
First Name:CAMERYN
Middle Name:
Last Name:FAULKNER
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 1:5140 JIMMY LEE SMITH PKWY STE 101
Mailing Address - Street 2:
Mailing Address - City:HIRAM
Mailing Address - State:GA
Mailing Address - Zip Code:30141-2746
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5140 JIMMY LEE SMITH PKWY
Practice Address - Street 2:
Practice Address - City:HIRAM
Practice Address - State:GA
Practice Address - Zip Code:30141-2745
Practice Address - Country:US
Practice Address - Phone:770-439-1038
Practice Address - Fax:504-364-8968
Is Sole Proprietor?:No
Enumeration Date:2018-06-27
Last Update Date:2024-09-23
Deactivation Date:2024-08-22
Deactivation Code:
Reactivation Date:2024-09-04
Provider Licenses
StateLicense IDTaxonomies
GADN123574122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist