Basic Information
Provider Information | |||||||||
NPI: | 1255054516 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | REESE | ||||||||
FirstName: | RAVEN | ||||||||
MiddleName: | VALISHA | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | DDS | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 7235 RAND DR | ||||||||
Address2: |   | ||||||||
City: | DOUGLASVILLE | ||||||||
State: | GA | ||||||||
PostalCode: | 301355628 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6783870249 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1699 DULUTH HWY | ||||||||
Address2: |   | ||||||||
City: | LAWRENCEVILLE | ||||||||
State: | GA | ||||||||
PostalCode: | 300435010 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7703381963 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/22/2022 | ||||||||
LastUpdateDate: | 09/22/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 09/22/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | DN122869 | GA | Y |   | Dental Providers | Dentist | General Practice |
No ID Information.