Provider Demographics
NPI:1790834083
Name:CARDONA-ROHENA, YADIRA (DMD)
Entity Type:Individual
Prefix:DR
First Name:YADIRA
Middle Name:
Last Name:CARDONA-ROHENA
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:DR
Other - First Name:YADIRA
Other - Middle Name:
Other - Last Name:LONTZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DMD
Mailing Address - Street 1:4285 JIM MOORE RD
Mailing Address - Street 2:BLDG 100, SUITE 104
Mailing Address - City:DACULA
Mailing Address - State:GA
Mailing Address - Zip Code:30019-1609
Mailing Address - Country:US
Mailing Address - Phone:678-835-1135
Mailing Address - Fax:678-835-1136
Practice Address - Street 1:4285 JIM MOORE RD
Practice Address - Street 2:BLDG 100, SUITE 104
Practice Address - City:DACULA
Practice Address - State:GA
Practice Address - Zip Code:30019-1609
Practice Address - Country:US
Practice Address - Phone:678-835-1135
Practice Address - Fax:678-835-1136
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-09
Last Update Date:2020-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR26301223S0112X
NY051734-11223S0112X
GADN0134771223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA632481454NMedicaid