Provider Demographics
NPI:1487685665
Name:REILLY, ROBERT G (DMD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:G
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 1:12 MARTIN ST
Mailing Address - Street 2:
Mailing Address - City:WELLSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14895-1057
Mailing Address - Country:US
Mailing Address - Phone:585-593-4990
Mailing Address - Fax:585-593-4991
Practice Address - Street 1:12 MARTIN ST
Practice Address - Street 2:
Practice Address - City:WELLSVILLE
Practice Address - State:NY
Practice Address - Zip Code:14895-1057
Practice Address - Country:US
Practice Address - Phone:585-593-4990
Practice Address - Fax:585-593-4991
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0448551223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice