Provider Demographics
NPI:1407156680
Name:REILLY, PATRICK JAMES (DMD)
Entity Type:Individual
Prefix:DR
First Name:PATRICK
Middle Name:JAMES
Last Name:REILLY
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2701 GARDENIA AVE
Mailing Address - Street 2:APT 2
Mailing Address - City:BEAVERCREEK
Mailing Address - State:OH
Mailing Address - Zip Code:45431-2081
Mailing Address - Country:US
Mailing Address - Phone:307-272-9280
Mailing Address - Fax:
Practice Address - Street 1:4881 SUGAR MAPLE DR
Practice Address - Street 2:
Practice Address - City:WRIGHT PATTERSON AFB
Practice Address - State:OH
Practice Address - Zip Code:45433-5546
Practice Address - Country:US
Practice Address - Phone:935-257-9631
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-22
Last Update Date:2010-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO10314122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist