Healthcare Provider Details

I. General information

NPI: 1386798718
Provider Name (Legal Business Name): HENRY LEON DIVERSI JR. DMD MSD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/23/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1895 PHOENIX BLVD SUITE 138
ATLANTA GA
30349
US

IV. Provider business mailing address

1895 PHOENIX BLVD SUITE 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:
Title or Position:
Credential:
Phone: