Provider Demographics
NPI:1619235694
Name:GAUD-QUINTANA, SADJA (DMD)
Entity Type:Individual
Prefix:
First Name:SADJA
Middle Name:
Last Name:GAUD-QUINTANA
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3469 FENTON DR SE
Mailing Address - Street 2:
Mailing Address - City:SMYRNA
Mailing Address - State:GA
Mailing Address - Zip Code:30080-2392
Mailing Address - Country:US
Mailing Address - Phone:787-344-1946
Mailing Address - Fax:
Practice Address - Street 1:4373 JIMMY LEE SMITH PKWY
Practice Address - Street 2:
Practice Address - City:HIRAM
Practice Address - State:GA
Practice Address - Zip Code:30141-2629
Practice Address - Country:US
Practice Address - Phone:678-942-6085
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-27
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
GADN0146951223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program