Healthcare Provider Details

I. General information

NPI: 1184845273
Provider Name (Legal Business Name): PERIODONTAL ASSOCIATES PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/02/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1895 PHOENIX BLVD STE 138
ATLANTA GA
30349
US

IV. Provider business mailing address

1895 PHOENIX BLVD STE 138
ATLANTA GA
30349
US

V. Phone/Fax

Practice location:
  • Phone: 770-996-2900
  • Fax: 770-996-0403
Mailing address:
  • Phone: 770-996-2900
  • Fax: 770-996-0403

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number6518
License Number StateGA

VIII. Authorized Official

Name: DR. HENRY LEON DIVERSI JR.
Title or Position: PRESIDENT
Credential: DMD MSD
Phone: 770-996-2900