Provider Demographics
NPI:1780674879
Name:REAVES, ELMER LEONARD JR (DDS)
Entity Type:Individual
Prefix:DR
First Name:ELMER
Middle Name:LEONARD
Last Name:REAVES
Suffix:JR
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 1:1304 BRADDOCK AVE
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23455-4102
Mailing Address - Country:US
Mailing Address - Phone:757-363-9568
Mailing Address - Fax:
Practice Address - Street 1:1320 LASALLE AVE
Practice Address - Street 2:
Practice Address - City:HAMPTON
Practice Address - State:VA
Practice Address - Zip Code:23669-3801
Practice Address - Country:US
Practice Address - Phone:757-727-2585
Practice Address - Fax:757-727-4881
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04010052621223D0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223D0001XDental ProvidersDentistDental Public Health