Provider Demographics
NPI:1376721985
Name:DE LOS REYES, JOSE B (DMD)
Entity Type:Individual
Prefix:DR
First Name:JOSE
Middle Name:B
Last Name:DE LOS REYES
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:JOSE
Other - Middle Name:B
Other - Last Name:DE LOS REYES
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DMD
Mailing Address - Street 1:PO BOX 188
Mailing Address - Street 2:300 NORTH MILWAUKEE AVENUE SUITE A
Mailing Address - City:LAKE VILLA
Mailing Address - State:IL
Mailing Address - Zip Code:60046
Mailing Address - Country:US
Mailing Address - Phone:847-699-2358
Mailing Address - Fax:847-265-0744
Practice Address - Street 1:300 NORTH MILWAUKEE AVENUE
Practice Address - Street 2:SUITE A
Practice Address - City:LAKE VILLA
Practice Address - State:IL
Practice Address - Zip Code:60046
Practice Address - Country:US
Practice Address - Phone:847-699-2358
Practice Address - Fax:847-265-0744
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-06
Last Update Date:2008-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice