Provider Demographics
NPI:1700856838
Name:REILLY, KEVIN M (DDS)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:M
Last Name:REILLY
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 1:5507 NESCONSET HWY
Mailing Address - Street 2:SUITE 23
Mailing Address - City:MOUNT SINAI
Mailing Address - State:NY
Mailing Address - Zip Code:11766-2031
Mailing Address - Country:US
Mailing Address - Phone:631-473-4477
Mailing Address - Fax:631-473-8676
Practice Address - Street 1:5507 NESCONSET HWY
Practice Address - Street 2:SUITE 23
Practice Address - City:MOUNT SINAI
Practice Address - State:NY
Practice Address - Zip Code:11766-2031
Practice Address - Country:US
Practice Address - Phone:631-473-4477
Practice Address - Fax:631-473-8676
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0459071223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice