Provider Demographics
NPI:1740326438
Name:SAMUELS, RENEE DONNA MARIA (DDS)
Entity type:Individual
Prefix:DR
First Name:RENEE
Middle Name:DONNA MARIA
Last Name:SAMUELS
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 1:6051 FARMWOOD WAY
Mailing Address - Street 2:
Mailing Address - City:MABLETON
Mailing Address - State:GA
Mailing Address - Zip Code:30126
Mailing Address - Country:US
Mailing Address - Phone:770-964-0494
Mailing Address - Fax:
Practice Address - Street 1:5370 CAMPBELLTON FAIRBURN ROAD
Practice Address - Street 2:SUITE 130
Practice Address - City:FAIRBURN
Practice Address - State:GA
Practice Address - Zip Code:30213
Practice Address - Country:US
Practice Address - Phone:770-964-0494
Practice Address - Fax:770-964-0468
Is Sole Proprietor?:No
Enumeration Date:2007-01-29
Last Update Date:2008-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0126821223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice