Provider Demographics
NPI:1063870988
Name:DIAZ-VIDAL, NATASHA (DMD)
Entity type:Individual
Prefix:
First Name:NATASHA
Middle Name:
Last Name:DIAZ-VIDAL
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 1:171 DANIEL CREEK LN
Mailing Address - Street 2:
Mailing Address - City:SUGAR HILL
Mailing Address - State:GA
Mailing Address - Zip Code:30518-8029
Mailing Address - Country:US
Mailing Address - Phone:770-572-2480
Mailing Address - Fax:
Practice Address - Street 1:171 DANIEL CREEK LN
Practice Address - Street 2:
Practice Address - City:SUGAR HILL
Practice Address - State:GA
Practice Address - Zip Code:30518-8029
Practice Address - Country:US
Practice Address - Phone:770-572-2480
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-05
Last Update Date:2016-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0150011223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry