Provider Demographics
NPI:1609950757
Name:REILLY, SUSAN BOYD (DDS)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:BOYD
Last Name:REILLY
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3535 ROSWELL RD
Mailing Address - Street 2:SUITE 3
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30062-8826
Mailing Address - Country:US
Mailing Address - Phone:770-971-6656
Mailing Address - Fax:770-973-6659
Practice Address - Street 1:3535 ROSWELL RD
Practice Address - Street 2:SUITE 3
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30062-8826
Practice Address - Country:US
Practice Address - Phone:770-971-6656
Practice Address - Fax:770-973-6659
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAGA0119721223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice