Provider Demographics
NPI:1790990091
Name:REYNOLDS, JULIANE SIMONE (DDS)
Entity Type:Individual
Prefix:DR
First Name:JULIANE
Middle Name:SIMONE
Last Name:REYNOLDS
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 1:1134 SENOIA RD STE A2
Mailing Address - Street 2:
Mailing Address - City:TYRONE
Mailing Address - State:GA
Mailing Address - Zip Code:30290-1622
Mailing Address - Country:US
Mailing Address - Phone:770-964-9992
Mailing Address - Fax:770-964-9660
Practice Address - Street 1:1134 SENOIA RD
Practice Address - Street 2:
Practice Address - City:TYRONE
Practice Address - State:GA
Practice Address - Zip Code:30290-1622
Practice Address - Country:US
Practice Address - Phone:770-964-9992
Practice Address - Fax:770-964-9992
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-11
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0134881223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA258308258AMedicaid