Provider Demographics
NPI:1437287836
Name:REYNOLDS, STACEY (DDS)
Entity Type:Individual
Prefix:DR
First Name:STACEY
Middle Name:
Last Name:REYNOLDS
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:STACEY
Other - Middle Name:CAMILLE
Other - Last Name:REYNOLDS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:585 STEWART AVE STE LL60
Mailing Address - Street 2:
Mailing Address - City:GARDEN CITY
Mailing Address - State:NY
Mailing Address - Zip Code:11530-4786
Mailing Address - Country:US
Mailing Address - Phone:516-222-5100
Mailing Address - Fax:516-222-5107
Practice Address - Street 1:585 STEWART AVE STE LL60
Practice Address - Street 2:
Practice Address - City:GARDEN CITY
Practice Address - State:NY
Practice Address - Zip Code:11530-4786
Practice Address - Country:US
Practice Address - Phone:516-222-5100
Practice Address - Fax:516-222-5107
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-28
Last Update Date:2023-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD142981223P0221X
NY0489601223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry