Provider Demographics
NPI:1659939585
Name:REYNOLDS, MARY CATHERINE (DMD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:CATHERINE
Last Name:REYNOLDS
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:208 CAMBRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:MS
Mailing Address - Zip Code:39110-8975
Mailing Address - Country:US
Mailing Address - Phone:601-466-0229
Mailing Address - Fax:
Practice Address - Street 1:106 CENTRAL BLVD
Practice Address - Street 2:
Practice Address - City:FLORA
Practice Address - State:MS
Practice Address - Zip Code:39071-8003
Practice Address - Country:US
Practice Address - Phone:601-879-0031
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-05
Last Update Date:2019-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS4065-19122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist