Provider Demographics
NPI:1609823772
Name:DIAB, WADDAH A (DDS)
Entity Type:Individual
Prefix:DR
First Name:WADDAH
Middle Name:A
Last Name:DIAB
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:DR
Other - First Name:WADE
Other - Middle Name:A
Other - Last Name:DIAB
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:3900 FREY RD NW
Mailing Address - Street 2:SUITE 102
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30144-5408
Mailing Address - Country:US
Mailing Address - Phone:770-426-1062
Mailing Address - Fax:
Practice Address - Street 1:3900 FREY RD NW
Practice Address - Street 2:SUITE 102
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30144-5408
Practice Address - Country:US
Practice Address - Phone:770-426-1062
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA113441223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics