Provider Demographics
NPI:1467558650
Name:REDIE, DANIEL TESFA (DDS)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:TESFA
Last Name:REDIE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1849 HWY 138
Mailing Address - Street 2:
Mailing Address - City:RIVERDALE
Mailing Address - State:GA
Mailing Address - Zip Code:30296
Mailing Address - Country:US
Mailing Address - Phone:770-996-5850
Mailing Address - Fax:770-996-5851
Practice Address - Street 1:1849 HWY 138
Practice Address - Street 2:
Practice Address - City:RIVERDALE
Practice Address - State:GA
Practice Address - Zip Code:30296
Practice Address - Country:US
Practice Address - Phone:770-996-5850
Practice Address - Fax:770-996-5851
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN012618122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GADN012618OtherGA DENTAL LICENSE
GADN012618OtherGA DENTAL LICENSE