Provider Demographics
NPI:1093880924
Name:REYNOLDS, BRADLEY G (DMD)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:G
Last Name:REYNOLDS
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:58 PALEO PL
Mailing Address - Street 2:
Mailing Address - City:INDIAN SPRINGS
Mailing Address - State:AL
Mailing Address - Zip Code:35124-3724
Mailing Address - Country:US
Mailing Address - Phone:205-995-2027
Mailing Address - Fax:
Practice Address - Street 1:114 E BROOKWOOD ROAD
Practice Address - Street 2:
Practice Address - City:MIDFIELD
Practice Address - State:AL
Practice Address - Zip Code:35228
Practice Address - Country:US
Practice Address - Phone:205-923-6828
Practice Address - Fax:205-923-1680
Is Sole Proprietor?:No
Enumeration Date:2006-11-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL4980122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL51504362REYOtherBLUE CROSS AND BLUE SHIEL