Provider Demographics
NPI:1326047515
Name:GLENN A REAVES DDS
Entity Type:Organization
Organization Name:GLENN A REAVES DDS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER - GENERAL DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:GLENN
Authorized Official - Middle Name:ASHLEY
Authorized Official - Last Name:REAVES
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:315-736-0139
Mailing Address - Street 1:4301 MIDDLE SETTLEMENT RD
Mailing Address - Street 2:
Mailing Address - City:NEW HARTFORD
Mailing Address - State:NY
Mailing Address - Zip Code:13413
Mailing Address - Country:US
Mailing Address - Phone:315-736-0139
Mailing Address - Fax:315-768-6148
Practice Address - Street 1:4301 MIDDLE SETTLEMENT RD
Practice Address - Street 2:
Practice Address - City:NEW HARTFORD
Practice Address - State:NY
Practice Address - Zip Code:13413
Practice Address - Country:US
Practice Address - Phone:315-736-0139
Practice Address - Fax:315-768-6148
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-19
Last Update Date:2016-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY032955122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00551102Medicaid