Provider Demographics
NPI:1356462600
Name:REYNOLDS, THOMAS G
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:G
Last Name:REYNOLDS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9733 USTICK RD
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704
Mailing Address - Country:US
Mailing Address - Phone:208-375-8720
Mailing Address - Fax:
Practice Address - Street 1:9733 USTICK RD
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-5202
Practice Address - Country:US
Practice Address - Phone:208-375-8720
Practice Address - Fax:208-375-8734
Is Sole Proprietor?:No
Enumeration Date:2007-04-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-13141223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice