Provider Demographics
NPI:1255054516
Name:REESE, RAVEN VALISHA (DDS)
Entity type:Individual
Prefix:
First Name:RAVEN
Middle Name:VALISHA
Last Name:REESE
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 1:7235 RAND DR
Mailing Address - Street 2:
Mailing Address - City:DOUGLASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30135-5628
Mailing Address - Country:US
Mailing Address - Phone:678-387-0249
Mailing Address - Fax:
Practice Address - Street 1:1699 DULUTH HWY
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30043-5010
Practice Address - Country:US
Practice Address - Phone:770-338-1963
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-22
Last Update Date:2022-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN1228691223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice