Provider Demographics
NPI:1073749529
Name:REAGAN, JEFFERY GLEN (DDS)
Entity Type:Individual
Prefix:
First Name:JEFFERY
Middle Name:GLEN
Last Name:REAGAN
Suffix:
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 1:311 W 43RD ST
Mailing Address - Street 2:SUITE 1405
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10036-6413
Mailing Address - Country:US
Mailing Address - Phone:212-581-5050
Mailing Address - Fax:
Practice Address - Street 1:311 W 43RD ST
Practice Address - Street 2:SUITE 1405
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10036-6413
Practice Address - Country:US
Practice Address - Phone:212-581-5050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-10
Last Update Date:2010-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0474511223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics