Provider Demographics
NPI:1255400966
Name:RONDENO, DEIDRA (DDS)
Entity type:Individual
Prefix:DR
First Name:DEIDRA
Middle Name:
Last Name:RONDENO
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:DEIDRA
Other - Middle Name:
Other - Last Name:RONDENO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:52 EXECUTIVE PARK SOUTH NE
Mailing Address - Street 2:STE 5203
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30329-2217
Mailing Address - Country:US
Mailing Address - Phone:404-942-0086
Mailing Address - Fax:208-955-2434
Practice Address - Street 1:52 EXECUTIVE PARK SOUTH NE
Practice Address - Street 2:STE 5203
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30329-2217
Practice Address - Country:US
Practice Address - Phone:404-942-0086
Practice Address - Fax:208-955-2434
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN011717122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist