Provider Demographics
NPI:1467618199
Name:REAGAN, DAVID L (DDS)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:L
Last Name:REAGAN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:DR
Other - First Name:DAVID
Other - Middle Name:L
Other - Last Name:REAGAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:11401 HEACOCK ST
Mailing Address - Street 2:SUITE 320
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92557-7908
Mailing Address - Country:US
Mailing Address - Phone:951-247-7040
Mailing Address - Fax:951-247-5092
Practice Address - Street 1:11401 HEACOCK ST
Practice Address - Street 2:SUITE 320
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92557-7908
Practice Address - Country:US
Practice Address - Phone:951-247-7040
Practice Address - Fax:951-247-5092
Is Sole Proprietor?:No
Enumeration Date:2008-08-01
Last Update Date:2008-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA32166122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG90361-01OtherDENTICAL