Provider Demographics
NPI:1376542399
Name:REAVES, GLENN ASHLEY (DDS)
Entity Type:Individual
Prefix:DR
First Name:GLENN
Middle Name:ASHLEY
Last Name:REAVES
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 1:4301 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
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-20
Last Update Date:2016-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY032955122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00551102Medicaid