Healthcare Provider Details

I. General information

NPI: 1720182017
Provider Name (Legal Business Name): WALTER W REID III DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/08/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

570 W LANIER AVE BLDG #2
FAYETTEVILLE GA
30214-7649
US

IV. Provider business mailing address

5050 MONTCALM DR SW
ATLANTA GA
30331-8421
US

V. Phone/Fax

Practice location:
  • Phone: 678-836-2128
  • Fax: 770-460-7307
Mailing address:
  • Phone: 404-344-1137
  • Fax: 404-344-7810

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number10736
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: