Provider Demographics
NPI:1790212470
Name:REYNOLDS, LEVI (DDS)
Entity Type:Individual
Prefix:
First Name:LEVI
Middle Name:
Last Name:REYNOLDS
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 1:2921 5TH AVE NE STE 110
Mailing Address - Street 2:
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98372-7044
Mailing Address - Country:US
Mailing Address - Phone:253-841-3173
Mailing Address - Fax:
Practice Address - Street 1:2921 5TH AVE NE STE 110
Practice Address - Street 2:
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98372-7044
Practice Address - Country:US
Practice Address - Phone:253-592-3687
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-12
Last Update Date:2022-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
WADE608654591223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program