Provider Demographics
NPI:1760794150
Name:MEESA, NAGARJUNA (DDS)
Entity Type:Individual
Prefix:
First Name:NAGARJUNA
Middle Name:
Last Name:MEESA
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 1:630 WESCOTT AVE
Mailing Address - Street 2:
Mailing Address - City:SUWANEE
Mailing Address - State:GA
Mailing Address - Zip Code:30024-5539
Mailing Address - Country:US
Mailing Address - Phone:215-500-5012
Mailing Address - Fax:
Practice Address - Street 1:1030 DULUTH HWY
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30043-5215
Practice Address - Country:US
Practice Address - Phone:770-995-1957
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-14
Last Update Date:2023-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI65661223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1760794150Medicaid