=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396710216
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | VISHANT NATH D.M.D
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/22/2006
-----------------------------------------------------
Last Update Date | 10/30/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10930 CRABAPPLE RD SUITE 106
-----------------------------------------------------
City | ROSWELL
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30075-5813
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-352-1090
-----------------------------------------------------
Fax | 770-277-5637
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2012 IVEY CHASE DR
-----------------------------------------------------
City | DACULA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30019-7884
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-277-5637
-----------------------------------------------------
Fax | 770-277-5637
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0221X
-----------------------------------------------------
Taxonomy Name | Pediatric Dentistry
-----------------------------------------------------
License Number | DN013057
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number | DN013057
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------