Provider Demographics
NPI:1396710901
Name:REDDICK, DEBRA M (DDS)
Entity type:Individual
Prefix:DR
First Name:DEBRA
Middle Name:M
Last Name:REDDICK
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 1:400 PLAYERS CT
Mailing Address - Street 2:
Mailing Address - City:MCDONOUGH
Mailing Address - State:GA
Mailing Address - Zip Code:30253-8810
Mailing Address - Country:US
Mailing Address - Phone:908-285-6051
Mailing Address - Fax:
Practice Address - Street 1:4458 JONESBORO RD
Practice Address - Street 2:
Practice Address - City:FOREST PARK
Practice Address - State:GA
Practice Address - Zip Code:30297-4314
Practice Address - Country:US
Practice Address - Phone:470-878-3512
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-18
Last Update Date:2021-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0130601223D0001X, 1223G0001X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No1223D0001XDental ProvidersDentistDental Public Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA545055622AMedicaid
GA545055622BMedicaid
GA9180174Medicaid