Provider Demographics
NPI:1336907534
Name:METAYER, REVENEL REVERT
Entity type:Individual
Prefix:MR
First Name:REVENEL
Middle Name:REVERT
Last Name:METAYER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2570 BLACKMON DR STE 310
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30033-6197
Mailing Address - Country:US
Mailing Address - Phone:239-206-9099
Mailing Address - Fax:
Practice Address - Street 1:2570 BLACKMON DR STE 310
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30033-6197
Practice Address - Country:US
Practice Address - Phone:678-203-3462
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-12
Last Update Date:2025-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN123860122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty