Provider Demographics
NPI:1710679386
Name:REYNOLDS, JACOB DANIEL
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:DANIEL
Last Name:REYNOLDS
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 1:2341 E JOHN HOLLADAY CT
Mailing Address - Street 2:
Mailing Address - City:HOLLADAY
Mailing Address - State:UT
Mailing Address - Zip Code:84117-4628
Mailing Address - Country:US
Mailing Address - Phone:801-608-5664
Mailing Address - Fax:
Practice Address - Street 1:2090 E 2100 S
Practice Address - Street 2:
Practice Address - City:SLC
Practice Address - State:UT
Practice Address - Zip Code:84109-1152
Practice Address - Country:US
Practice Address - Phone:801-486-1155
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-23
Last Update Date:2023-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT13403126-99231223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice