Provider Demographics
NPI:1396710216
Name:NATH, VISHANT (DMD)
Entity type:Individual
Prefix:DR
First Name:VISHANT
Middle Name:
Last Name:NATH
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2012 IVEY CHASE DR
Mailing Address - Street 2:
Mailing Address - City:DACULA
Mailing Address - State:GA
Mailing Address - Zip Code:30019-7884
Mailing Address - Country:US
Mailing Address - Phone:770-277-5637
Mailing Address - Fax:770-277-5637
Practice Address - Street 1:10930 CRABAPPLE RD
Practice Address - Street 2:SUITE 106
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30075-5813
Practice Address - Country:US
Practice Address - Phone:678-352-1090
Practice Address - Fax:770-277-5637
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-22
Last Update Date:2016-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0130571223P0221X, 1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA761564386DMedicaid