Provider Demographics
NPI:1407941263
Name:NWADIKE, DARIOUS N (DDS)
Entity Type:Individual
Prefix:DR
First Name:DARIOUS
Middle Name:N
Last Name:NWADIKE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2255 E WEST CONNECTOR
Mailing Address - Street 2:
Mailing Address - City:AUSTELL
Mailing Address - State:GA
Mailing Address - Zip Code:30106-8187
Mailing Address - Country:US
Mailing Address - Phone:770-319-8110
Mailing Address - Fax:770-319-7446
Practice Address - Street 1:2255 E WEST CONNECTOR
Practice Address - Street 2:
Practice Address - City:AUSTELL
Practice Address - State:GA
Practice Address - Zip Code:30106
Practice Address - Country:US
Practice Address - Phone:770-319-8110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2018-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0120561223G0001X
GADN0120561223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00912942BMedicaid