Provider Demographics
NPI:1861654626
Name:REYNOLDS, MICHAEL THOMAS (DDS)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:THOMAS
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 1:625 E. NICOLLET BLVD
Mailing Address - Street 2:SUITE 340
Mailing Address - City:BURNSVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55337
Mailing Address - Country:US
Mailing Address - Phone:952-435-0370
Mailing Address - Fax:952-435-0377
Practice Address - Street 1:625 E. NICOLLET BLVD
Practice Address - Street 2:SUITE 340
Practice Address - City:BURNSVILLE
Practice Address - State:MN
Practice Address - Zip Code:55337
Practice Address - Country:US
Practice Address - Phone:952-435-0370
Practice Address - Fax:952-435-0377
Is Sole Proprietor?:No
Enumeration Date:2008-07-01
Last Update Date:2019-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND127251223E0200X
IA302631223G0001X
IA8815390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes1223E0200XDental ProvidersDentistEndodontics
No1223G0001XDental ProvidersDentistGeneral Practice