Provider Demographics
NPI:1376948182
Name:GILLESPIE, LATONYA F R (DDS)
Entity Type:Individual
Prefix:DR
First Name:LATONYA
Middle Name:F R
Last Name:GILLESPIE
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:MS
Other - First Name:LATONYA
Other - Middle Name:F R
Other - Last Name:GILLESPIE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:210 SHORELINE DR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30215-4665
Mailing Address - Country:US
Mailing Address - Phone:404-729-5159
Mailing Address - Fax:
Practice Address - Street 1:1910 HIGHWAY 20 SE STE 100
Practice Address - Street 2:
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30013-2074
Practice Address - Country:US
Practice Address - Phone:404-729-5159
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-23
Last Update Date:2019-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN014891122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist