Provider Demographics
NPI:1821138769
Name:REYES, EDITHA R A (DMD)
Entity Type:Individual
Prefix:DR
First Name:EDITHA
Middle Name:R A
Last Name:REYES
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 10659
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60610
Mailing Address - Country:US
Mailing Address - Phone:312-550-6166
Mailing Address - Fax:772-772-4092
Practice Address - Street 1:3111 N MILWAUKEE AVENUE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60618
Practice Address - Country:US
Practice Address - Phone:773-588-9705
Practice Address - Fax:770-588-9706
Is Sole Proprietor?:No
Enumeration Date:2007-02-08
Last Update Date:2010-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190207621223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice