Provider Demographics
NPI:1871235978
Name:REID, AUTUMN VANDIVER (RDH,BSDH)
Entity Type:Individual
Prefix:
First Name:AUTUMN
Middle Name:VANDIVER
Last Name:REID
Suffix:
Gender:F
Credentials:RDH,BSDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:273 THE BLVD
Mailing Address - Street 2:
Mailing Address - City:NEWNAN
Mailing Address - State:GA
Mailing Address - Zip Code:30263-6254
Mailing Address - Country:US
Mailing Address - Phone:770-328-9834
Mailing Address - Fax:
Practice Address - Street 1:201 NEWNAN CROSSING BYP
Practice Address - Street 2:
Practice Address - City:NEWNAN
Practice Address - State:GA
Practice Address - Zip Code:30265-1063
Practice Address - Country:US
Practice Address - Phone:678-621-6410
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-09
Last Update Date:2022-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADH011214124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist