MEDICARE: DR. REGINALD GARY WOODELL D.D.S.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	8104	GA
2	1223P0700X	Prosthodontics	8104	GA

General Provider Information

NPI Number	:	1912147539
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. REGINALD GARY WOODELL D.D.S.

Provider Business Mailing Address
First Line	:	7571 HIGHWAY 78
Second Line	:
City	:	WINSTON
State	:	GA
Zip	:	30187-1449
Country	:	US
Telephone Number	:	404-933-6031
Fax Number	:

Provider Business Practice Location Address
First Line	:	7571 HIGHWAY 78
Second Line	:
City	:	WINSTON
State	:	GA
Zip	:	30187-1449
Country	:	US
Telephone Number	:	404-933-6031
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/22/2009
Last Update Date	:	02/22/2009

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