MEDICARE: SEMHAR G DESTA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	DN123551	GA

General Provider Information

NPI Number	:	1053142711
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SEMHAR G DESTA

Provider Business Mailing Address
First Line	:	879 LONGBRANCH LN
Second Line	:
City	:	DOUGLASVILLE
State	:	GA
Zip	:	30134-8320
Country	:	US
Telephone Number	:	317-737-0529
Fax Number	:

Provider Business Practice Location Address
First Line	:	5495 OLD NATIONAL HWY
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30349-3252
Country	:	US
Telephone Number	:	470-878-3550
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/13/2024
Last Update Date	:	10/17/2024

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Directions to “ SEMHAR G DESTA ” Practice Location

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