Provider Demographics
NPI:1518342179
Name:REAVIS, DARYL K (DMD)
Entity Type:Individual
Prefix:
First Name:DARYL
Middle Name:K
Last Name:REAVIS
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 1:1245 FULTON AVE
Mailing Address - Street 2:
Mailing Address - City:COOS BAY
Mailing Address - State:OR
Mailing Address - Zip Code:97420-2895
Mailing Address - Country:US
Mailing Address - Phone:541-888-6433
Mailing Address - Fax:541-888-7505
Practice Address - Street 1:1245 FULTON AVE
Practice Address - Street 2:
Practice Address - City:COOS BAY
Practice Address - State:OR
Practice Address - Zip Code:97420-2895
Practice Address - Country:US
Practice Address - Phone:541-888-6433
Practice Address - Fax:541-888-7505
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-24
Last Update Date:2015-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD01503122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist