Provider Demographics
NPI:1336296250
Name:REYNOLDS, ROBERT K (DDS)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:K
Last Name:REYNOLDS
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 1:3259 E SUNSHINE ST
Mailing Address - Street 2:SUITE Q
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65804-2143
Mailing Address - Country:US
Mailing Address - Phone:417-881-3220
Mailing Address - Fax:417-881-6473
Practice Address - Street 1:3259 E SUNSHINE ST
Practice Address - Street 2:SUITE Q
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-2143
Practice Address - Country:US
Practice Address - Phone:417-881-3220
Practice Address - Fax:417-881-6473
Is Sole Proprietor?:No
Enumeration Date:2007-01-04
Last Update Date:2014-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO0150361223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO015036OtherDENTAL LICENSE
MO43-1852819Medicare UPIN