Provider Demographics
NPI:1255696076
Name:WEST, RENEE ANTOINETTE (DMD)
Entity type:Individual
Prefix:DR
First Name:RENEE
Middle Name:ANTOINETTE
Last Name:WEST
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3050 MLK JR DR SW STE A
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30311-1500
Mailing Address - Country:US
Mailing Address - Phone:404-756-1400
Mailing Address - Fax:
Practice Address - Street 1:3050 MLK JR DR SW STE A
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30311-1500
Practice Address - Country:US
Practice Address - Phone:404-756-1400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-09
Last Update Date:2021-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0146751223G0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003140754AMedicaid