MEDICARE: DR. DEIDRA RONDENO DDS

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	DN011717	GA

General Provider Information

NPI Number	:	1255400966
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DEIDRA RONDENO DDS

Provider Business Mailing Address
First Line	:	52 EXECUTIVE PARK SOUTH NE
Second Line	:	STE 5203
City	:	ATLANTA
State	:	GA
Zip	:	30329-2217
Country	:	US
Telephone Number	:	404-942-0086
Fax Number	:	208-955-2434

Provider Business Practice Location Address
First Line	:	52 EXECUTIVE PARK SOUTH NE
Second Line	:	STE 5203
City	:	ATLANTA
State	:	GA
Zip	:	30329-2217
Country	:	US
Telephone Number	:	404-942-0086
Fax Number	:	208-955-2434

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

Provider Enumeration Date	:	11/07/2006
Last Update Date	:	07/08/2007

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