Provider Demographics
NPI:1801571500
Name:GAILLARD, REBECCA (DMD)
Entity type:Individual
Prefix:DR
First Name:REBECCA
Middle Name:
Last Name:GAILLARD
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 1:1205 IVY BROOK LN NE
Mailing Address - Street 2:
Mailing Address - City:BROOKHAVEN
Mailing Address - State:GA
Mailing Address - Zip Code:30319-4706
Mailing Address - Country:US
Mailing Address - Phone:404-731-0503
Mailing Address - Fax:
Practice Address - Street 1:5461 MERIDIAN MARK RD STE 200
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342-4014
Practice Address - Country:US
Practice Address - Phone:404-731-0503
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-20
Last Update Date:2023-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN123088122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty