Provider Demographics
NPI:1073545919
Name:REAGAN, JON L JR (DDS)
Entity Type:Individual
Prefix:
First Name:JON
Middle Name:L
Last Name:REAGAN
Suffix:JR
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1112 BAXTER ST
Mailing Address - Street 2:
Mailing Address - City:NEOSHO
Mailing Address - State:MO
Mailing Address - Zip Code:64850-7814
Mailing Address - Country:US
Mailing Address - Phone:417-451-2403
Mailing Address - Fax:417-451-2200
Practice Address - Street 1:1112 BAXTER ST
Practice Address - Street 2:
Practice Address - City:NEOSHO
Practice Address - State:MO
Practice Address - Zip Code:64850-7814
Practice Address - Country:US
Practice Address - Phone:417-451-2403
Practice Address - Fax:417-451-2200
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO155441223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice