Provider Demographics
NPI:1578531364
Name:REYNOLDS, DALE S (MD PHD)
Entity Type:Individual
Prefix:
First Name:DALE
Middle Name:S
Last Name:REYNOLDS
Suffix:
Gender:M
Credentials:MD PHD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2330 TROOP DR
Mailing Address - Street 2:SUITE 104
Mailing Address - City:SARTELL
Mailing Address - State:MN
Mailing Address - Zip Code:56377-4530
Mailing Address - Country:US
Mailing Address - Phone:320-230-8555
Mailing Address - Fax:320-230-8556
Practice Address - Street 1:2330 TROOP DR
Practice Address - Street 2:SUITE 104
Practice Address - City:SARTELL
Practice Address - State:MN
Practice Address - Zip Code:56377-4530
Practice Address - Country:US
Practice Address - Phone:320-230-8555
Practice Address - Fax:320-230-8556
Is Sole Proprietor?:No
Enumeration Date:2006-03-09
Last Update Date:2009-05-06
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MN45473207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN569S2CEOtherBLUE CROSEE BLUE SHIELD
MN80793200Medicaid
G73652Medicare UPIN
MN80793200Medicaid