Provider Demographics
NPI:1255101507
Name:VARGHESE, KEZIA (DDS)
Entity type:Individual
Prefix:
First Name:KEZIA
Middle Name:
Last Name:VARGHESE
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 1:1306 JEFFERSON CT
Mailing Address - Street 2:
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30005-3828
Mailing Address - Country:US
Mailing Address - Phone:770-330-5334
Mailing Address - Fax:
Practice Address - Street 1:890 DAWSONVILLE HWY STE F
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501-2607
Practice Address - Country:US
Practice Address - Phone:943-473-3854
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-08
Last Update Date:2024-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
GADN123321122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program