Healthcare Provider Details

I. General information

NPI: 1730385931
Provider Name (Legal Business Name): REYNALDO REESE DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2007
Last Update Date: 05/17/2021
Certification Date: 05/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4020 CHAPEL HILL RD
DOUGLASVILLE GA
30135-2829
US

IV. Provider business mailing address

8926 ELINA ROSE
DOUGLASVILLE GA
30134-1664
US

V. Phone/Fax

Practice location:
  • Phone: 770-949-2400
  • Fax: 770-949-2244
Mailing address:
  • Phone: 678-391-8577
  • Fax: 770-441-0299

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number12778
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: