Provider Demographics
NPI:1518382449
Name:REYNOLDSBURG DENTAL GROUP
Entity Type:Organization
Organization Name:REYNOLDSBURG DENTAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RAGHU
Authorized Official - Middle Name:
Authorized Official - Last Name:REDDY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:614-535-8271
Mailing Address - Street 1:5303 E LIVINGSTON AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43232-2864
Mailing Address - Country:US
Mailing Address - Phone:614-866-8111
Mailing Address - Fax:
Practice Address - Street 1:5303 E LIVINGSTON AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43232-2864
Practice Address - Country:US
Practice Address - Phone:614-866-8111
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-01
Last Update Date:2014-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH12345122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty