Provider Demographics
NPI:1407050586
Name:REARDON, DANIEL PETER (DDS)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:PETER
Last Name:REARDON
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 1:7111 DELLWOOD CT
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87402-5045
Mailing Address - Country:US
Mailing Address - Phone:505-327-5533
Mailing Address - Fax:
Practice Address - Street 1:6588 E MAIN ST
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87402-5122
Practice Address - Country:US
Practice Address - Phone:505-326-6800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD28801223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice