Healthcare Provider Details

I. General information

NPI: 1215846902
Provider Name (Legal Business Name): WADE A DIAB DDS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/07/2026
Last Update Date: 09/07/2026
Certification Date: 09/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4125 GEORGE BUSBEE PKWY NW
KENNESAW GA
30144-7107
US

IV. Provider business mailing address

4125 GEORGE BUSBEE PKWY NW
KENNESAW GA
30144-7107
US

V. Phone/Fax

Practice location:
  • Phone: 770-426-1062
  • Fax:
Mailing address:
  • Phone: 770-426-1062
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number
License Number StateNULL

VIII. Authorized Official

Name: MICHAELA MUNIZ
Title or Position: VP, PAYOR RELATIONS
Credential:
Phone: 469-324-3242