Individual
NICOLE WIDJAJA
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
DMD
Contact information
Practice address
1350 UPPER HEMBREE RD, ROSWELL, GA 30076-0928
(678) 920-7675
Mailing address
1350 UPPER HEMBREE RD, ROSWELL, GA 30076-0928
Taxonomy
Speciality
Code
Description
License number
State
1223G0001X
General Practice Dentistry
Primary
DN123505
GA
Other
Enumeration date
07/12/2024
Last updated
07/12/2024
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