Provider Demographics
NPI:1386031805
Name:REYNOLDS, EVAN STEWART
Entity Type:Individual
Prefix:
First Name:EVAN
Middle Name:STEWART
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:PO BOX 777
Mailing Address - Street 2:RICHLAND MEDICAL CENTER INC
Mailing Address - City:RICHLAND
Mailing Address - State:MO
Mailing Address - Zip Code:65556-0777
Mailing Address - Country:US
Mailing Address - Phone:573-765-5131
Mailing Address - Fax:
Practice Address - Street 1:304 W WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:RICHLAND
Practice Address - State:MO
Practice Address - Zip Code:65556-7101
Practice Address - Country:US
Practice Address - Phone:573-765-2510
Practice Address - Fax:573-765-2513
Is Sole Proprietor?:No
Enumeration Date:2015-04-22
Last Update Date:2015-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20150020191223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice