MEDICARE: DR. KENYATTA VICTORIA DEAN DO

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	207Q00000X	Family Medicine Physician	052265	GA

General Provider Information

NPI Number	:	1710964440
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KENYATTA VICTORIA DEAN DO

Provider Business Mailing Address
First Line	:	3495 PIEDMONT RD NE
Second Line	:	NINE PIEDMONT CENTER
City	:	ATLANTA
State	:	GA
Zip	:	30305-1717
Country	:	US
Telephone Number	:	404-364-7000
Fax Number	:	404-364-4732

Provider Business Practice Location Address
First Line	:	3650 STEVE REYNOLDS BLVD
Second Line	:	DEPARTMENT OF INTERNAL MEDICINE TEAM A
City	:	DULUTH
State	:	GA
Zip	:	30096-4506
Country	:	US
Telephone Number	:	770-931-6011
Fax Number	:

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

Provider Enumeration Date	:	12/23/2005
Last Update Date	:	01/13/2022

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