Provider Demographics
NPI:1629170816
Name:REA, JAMES ALLEN (DMD)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:ALLEN
Last Name:REA
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 1:109 QUAIL RUN
Mailing Address - Street 2:
Mailing Address - City:CARTERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62918-2335
Mailing Address - Country:US
Mailing Address - Phone:618-985-2312
Mailing Address - Fax:618-988-1866
Practice Address - Street 1:401 S 14TH ST
Practice Address - Street 2:
Practice Address - City:HERRIN
Practice Address - State:IL
Practice Address - Zip Code:62948-3801
Practice Address - Country:US
Practice Address - Phone:618-942-4525
Practice Address - Fax:618-988-1866
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice