Provider Demographics
NPI:1235265984
Name:REYNOLDS, TIMOTHY D (DMD)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:D
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 1:1110 LANCASTER RD STE 2
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:KY
Mailing Address - Zip Code:40475-8792
Mailing Address - Country:US
Mailing Address - Phone:859-623-6369
Mailing Address - Fax:859-623-9497
Practice Address - Street 1:1110 LANCASTER RD STE 2
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:KY
Practice Address - Zip Code:40475-8792
Practice Address - Country:US
Practice Address - Phone:859-623-6369
Practice Address - Fax:859-623-9497
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYKY60161223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice