Provider Demographics
NPI:1710544762
Name:PEREZ, REYNALDO
Entity Type:Individual
Prefix:
First Name:REYNALDO
Middle Name:
Last Name:PEREZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1126 N FRANCISCO AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60622-2712
Mailing Address - Country:US
Mailing Address - Phone:773-447-0065
Mailing Address - Fax:
Practice Address - Street 1:2266 N LINCOLN AVE STE 1
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60614-7601
Practice Address - Country:US
Practice Address - Phone:773-528-6485
Practice Address - Fax:773-528-6478
Is Sole Proprietor?:No
Enumeration Date:2019-05-24
Last Update Date:2019-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190321131223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice