Provider Demographics
NPI:1588669196
Name:REYNOLDS, BRIAN HUGH (DMD)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:HUGH
Last Name:REYNOLDS
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 1:5702 CANYON RANCH ROAD
Mailing Address - Street 2:
Mailing Address - City:LARAMIE
Mailing Address - State:WY
Mailing Address - Zip Code:82070
Mailing Address - Country:US
Mailing Address - Phone:618-420-1513
Mailing Address - Fax:618-632-5852
Practice Address - Street 1:1156 N. 22ND STREET
Practice Address - Street 2:SUITE A
Practice Address - City:LARAMIE
Practice Address - State:WY
Practice Address - Zip Code:82072
Practice Address - Country:US
Practice Address - Phone:307-755-0444
Practice Address - Fax:307-755-0808
Is Sole Proprietor?:No
Enumeration Date:2005-06-20
Last Update Date:2021-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019-0211641223G0001X
WY14711223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILT87434Medicare ID - Type Unspecified