Provider Demographics
NPI:1063259356
Name:WIDJAJA, NICOLE (DMD)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:WIDJAJA
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 1:1350 UPPER HEMBREE RD
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30076-0928
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1350 UPPER HEMBREE RD
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30076-0928
Practice Address - Country:US
Practice Address - Phone:678-920-7675
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-12
Last Update Date:2024-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN1235051223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice