Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223P0221X | Pediatric Dentist | DN015001 | GA |
NPI | 1063870988 |
---|---|
Provider Name | Natasha Diaz-Vidal |
First Address | Sugar Hill, GA 30518-8029 |
Second Address | Sugar Hill, GA 30518-8029 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 05/02/2016 |
Last Update Date | 05/02/2016 |