Provider Demographics
NPI:1184845273
Name:PERIODONTAL ASSOCIATES PC
Entity Type:Organization
Organization Name:PERIODONTAL ASSOCIATES PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:HENRY
Authorized Official - Middle Name:LEON
Authorized Official - Last Name:DIVERSI
Authorized Official - Suffix:JR
Authorized Official - Credentials:DMD MSD
Authorized Official - Phone:770-996-2900
Mailing Address - Street 1:1895 PHOENIX BLVD
Mailing Address - Street 2:STE 138
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30349
Mailing Address - Country:US
Mailing Address - Phone:770-996-2900
Mailing Address - Fax:770-996-0403
Practice Address - Street 1:1895 PHOENIX BLVD
Practice Address - Street 2:STE 138
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30349
Practice Address - Country:US
Practice Address - Phone:770-996-2900
Practice Address - Fax:770-996-0403
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA65181223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty