Provider Demographics
NPI:1649936253
Name:FLETCHER, RENEE G (EFDA)
Entity type:Individual
Prefix:MS
First Name:RENEE
Middle Name:G
Last Name:FLETCHER
Suffix:
Gender:F
Credentials:EFDA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:75 N LEXINGTON CT
Mailing Address - Street 2:
Mailing Address - City:ELLERSLIE
Mailing Address - State:GA
Mailing Address - Zip Code:31807-5362
Mailing Address - Country:US
Mailing Address - Phone:706-536-9240
Mailing Address - Fax:
Practice Address - Street 1:75 N LEXINGTON CT
Practice Address - Street 2:
Practice Address - City:ELLERSLIE
Practice Address - State:GA
Practice Address - Zip Code:31807-5362
Practice Address - Country:US
Practice Address - Phone:706-536-9240
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-09
Last Update Date:2021-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA123456789125K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes125K00000XDental ProvidersAdvanced Practice Dental Therapist