Provider Demographics
NPI:1942675723
Name:JIN, DIANA (DDS)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:
Last Name:JIN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4323 TACOMA TRCE
Mailing Address - Street 2:
Mailing Address - City:SUWANEE
Mailing Address - State:GA
Mailing Address - Zip Code:30024-8731
Mailing Address - Country:US
Mailing Address - Phone:626-246-2429
Mailing Address - Fax:
Practice Address - Street 1:4323 TACOMA TRCE
Practice Address - Street 2:
Practice Address - City:SUWANEE
Practice Address - State:GA
Practice Address - Zip Code:30024-8731
Practice Address - Country:US
Practice Address - Phone:626-246-2429
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-05
Last Update Date:2022-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE60865949122300000X, 1223D0001X
CA651341223G0001X
GADN122784122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223D0001XDental ProvidersDentistDental Public Health
No1223G0001XDental ProvidersDentistGeneral Practice