Provider Demographics
NPI:1194132308
Name:PAEZ, LIDA (DMD)
Entity type:Individual
Prefix:DR
First Name:LIDA
Middle Name:
Last Name:PAEZ
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 1:2400 PARKLAND DR NE
Mailing Address - Street 2:UNIT 118
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30324-3589
Mailing Address - Country:US
Mailing Address - Phone:678-641-7989
Mailing Address - Fax:
Practice Address - Street 1:3970 FIVE FORKS TRICKUM RD SW
Practice Address - Street 2:SUITE B
Practice Address - City:LILBURN
Practice Address - State:GA
Practice Address - Zip Code:30047-2339
Practice Address - Country:US
Practice Address - Phone:770-921-8442
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-20
Last Update Date:2014-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0147861223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice