Provider Demographics
NPI:1407043797
Name:REID, JACK HOLMES JR
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:HOLMES
Last Name:REID
Suffix:JR
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 1:911 PLANTATION BLVD
Mailing Address - Street 2:
Mailing Address - City:FAIRHOPE
Mailing Address - State:AL
Mailing Address - Zip Code:36532-2949
Mailing Address - Country:US
Mailing Address - Phone:251-928-9331
Mailing Address - Fax:
Practice Address - Street 1:911 PLANTATION BLVD
Practice Address - Street 2:
Practice Address - City:FAIRHOPE
Practice Address - State:AL
Practice Address - Zip Code:36532-2949
Practice Address - Country:US
Practice Address - Phone:251-928-9331
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-01
Last Update Date:2007-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL36251223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics