Provider Demographics
NPI:1548220650
Name:REAVIS, TERRY JUSTIN (DDS)
Entity Type:Individual
Prefix:DR
First Name:TERRY
Middle Name:JUSTIN
Last Name:REAVIS
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13302 S MEMORIAL DR
Mailing Address - Street 2:
Mailing Address - City:BIXBY
Mailing Address - State:OK
Mailing Address - Zip Code:74008-3114
Mailing Address - Country:US
Mailing Address - Phone:918-369-3990
Mailing Address - Fax:918-369-8505
Practice Address - Street 1:13302 S MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:BIXBY
Practice Address - State:OK
Practice Address - Zip Code:74008-3114
Practice Address - Country:US
Practice Address - Phone:918-369-3990
Practice Address - Fax:918-369-8505
Is Sole Proprietor?:No
Enumeration Date:2006-03-23
Last Update Date:2008-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK48431223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice