Provider Demographics
NPI:1881712180
Name:REILLY, JAMES WALLACE (DDS)
Entity type:Individual
Prefix:DR
First Name:JAMES
Middle Name:WALLACE
Last Name:REILLY
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:1150 HAMMOND DR NE STE E200
Mailing Address - Street 2:BUILDING E SUITE 200
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30328-8600
Mailing Address - Country:US
Mailing Address - Phone:770-395-6422
Mailing Address - Fax:770-321-3720
Practice Address - Street 1:1150 HAMMOND DR NE STE E200
Practice Address - Street 2:BUILDING E SUITE 200
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30328-8600
Practice Address - Country:US
Practice Address - Phone:770-395-6422
Practice Address - Fax:770-321-3720
Is Sole Proprietor?:No
Enumeration Date:2007-03-26
Last Update Date:2010-02-23
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA107371223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice