Provider Demographics
NPI:1295908614
Name:DANIEL REDIE GENERAL DENTISTRY
Entity type:Organization
Organization Name:DANIEL REDIE GENERAL DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:REDIE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-996-5850
Mailing Address - Street 1:1849 HIGHWAY 138 SW
Mailing Address - Street 2:
Mailing Address - City:RIVERDALE
Mailing Address - State:GA
Mailing Address - Zip Code:30296-1812
Mailing Address - Country:US
Mailing Address - Phone:770-996-5850
Mailing Address - Fax:
Practice Address - Street 1:1849 HIGHWAY 138 SW
Practice Address - Street 2:
Practice Address - City:RIVERDALE
Practice Address - State:GA
Practice Address - Zip Code:30296-1812
Practice Address - Country:US
Practice Address - Phone:770-996-5850
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-07
Last Update Date:2008-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA9180091OtherDORAL
GA100997OtherAVESIS