Provider Demographics
NPI:1073629788
Name:REAGOR, ANISSA LYNN (DDS)
Entity Type:Individual
Prefix:
First Name:ANISSA
Middle Name:LYNN
Last Name:REAGOR
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:ANISSA
Other - Middle Name:LYNN
Other - Last Name:SOMMERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 632040
Mailing Address - Street 2:
Mailing Address - City:NACOGDOCHES
Mailing Address - State:TX
Mailing Address - Zip Code:75963-2040
Mailing Address - Country:US
Mailing Address - Phone:936-560-1122
Mailing Address - Fax:936-560-1631
Practice Address - Street 1:1210 DOUGLASS RD
Practice Address - Street 2:
Practice Address - City:NACOGDOCHES
Practice Address - State:TX
Practice Address - Zip Code:75964-4904
Practice Address - Country:US
Practice Address - Phone:936-560-1122
Practice Address - Fax:936-560-1631
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2014-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX19573122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist