Provider Demographics
NPI:1386798718
Name:DIVERSI, HENRY LEON JR (DMD MSD)
Entity type:Individual
Prefix:DR
First Name:HENRY
Middle Name:LEON
Last Name:DIVERSI
Suffix:JR
Gender:M
Credentials:DMD MSD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1895 PHOENIX BLVD
Mailing Address - Street 2:SUITE 138
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30349
Mailing Address - Country:US
Mailing Address - Phone:770-996-2900
Mailing Address - Fax:770-996-0403
Practice Address - Street 1:1895 PHOENIX BLVD
Practice Address - Street 2:SUITE 138
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30349
Practice Address - Country:US
Practice Address - Phone:770-996-2900
Practice Address - Fax:770-996-0403
Is Sole Proprietor?:No
Enumeration Date:2007-01-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA65181223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics