Provider Demographics
NPI:1912636820
Name:MOLEDINA, NIDA
Entity type:Individual
Prefix:
First Name:NIDA
Middle Name:
Last Name:MOLEDINA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1320 STANLEY PARK DR
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30033-4429
Mailing Address - Country:US
Mailing Address - Phone:404-643-1115
Mailing Address - Fax:
Practice Address - Street 1:171 GWINNETT DR STE C
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-5686
Practice Address - Country:US
Practice Address - Phone:770-963-1941
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-07
Last Update Date:2024-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN1228421223G0001X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice