Provider Demographics
NPI:1043290851
Name:REYNOLDS, DEAN STANTON (OD)
Entity Type:Individual
Prefix:
First Name:DEAN
Middle Name:STANTON
Last Name:REYNOLDS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4025 JACKIE RD SE
Mailing Address - Street 2:
Mailing Address - City:RIO RANCHO
Mailing Address - State:NM
Mailing Address - Zip Code:87124-6610
Mailing Address - Country:US
Mailing Address - Phone:505-892-8411
Mailing Address - Fax:505-891-5497
Practice Address - Street 1:4025 JACKIE RD SE
Practice Address - Street 2:
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87124-6610
Practice Address - Country:US
Practice Address - Phone:505-892-8411
Practice Address - Fax:505-891-5497
Is Sole Proprietor?:No
Enumeration Date:2006-01-18
Last Update Date:2010-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMOP2264152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMNM01P037OtherBLUE CROSS BLUE SHEILD NM
NM2264OtherEYE MED ID
NMNMOP2264OtherLICENSE #
NM152W00000XMedicaid
85-0407195OtherGROUP EIN
0772190001Medicare NSC
NMT74971Medicare UPIN
NMNMOP2264OtherLICENSE #