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General NPI Number Information
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NPI Number | 1053142711
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Entity Type | Individual
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Provider Name | SEMHAR G DESTA
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Gender | Female
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Dates
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Enumeration Date | 08/13/2024
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Last Update Date | 10/17/2024
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Provider Practice Location Address
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Address Line | 5495 OLD NATIONAL HWY
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City | ATLANTA
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State | GA
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Zip | 30349-3252
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Country | US
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Telephone | 470-878-3550
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Fax |
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Provider Business Mailing Address
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Address Line | 879 LONGBRANCH LN
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City | DOUGLASVILLE
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State | GA
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Zip | 30134-8320
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Country | US
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Telephone | 317-737-0529
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | DN123551
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License Number State | GA
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