Provider Demographics
NPI:1699711416
Name:BOOKER, REGINALD DOUGLAS (DDS)
Entity type:Individual
Prefix:DR
First Name:REGINALD
Middle Name:DOUGLAS
Last Name:BOOKER
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:DR
Other - First Name:REGINALD
Other - Middle Name:
Other - Last Name:BOOKER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DDS
Mailing Address - Street 1:4005 WINDER HWY
Mailing Address - Street 2:STE. 110
Mailing Address - City:FLOWERY BRANCH
Mailing Address - State:GA
Mailing Address - Zip Code:30542-6564
Mailing Address - Country:US
Mailing Address - Phone:770-531-3232
Mailing Address - Fax:
Practice Address - Street 1:4005 WINDER HWY
Practice Address - Street 2:#100
Practice Address - City:FLOWERY BRANCH
Practice Address - State:GA
Practice Address - Zip Code:30542-6564
Practice Address - Country:US
Practice Address - Phone:770-531-3232
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-21
Last Update Date:2014-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0134641223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA813355373AMedicaid