Provider Demographics
NPI:1891468641
Name:REYNOLDS, JUAN CAMILO (DDS)
Entity Type:Individual
Prefix:
First Name:JUAN
Middle Name:CAMILO
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 1:650 W SOUTH TEMPLE APT C108
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84104-1041
Mailing Address - Country:US
Mailing Address - Phone:918-907-1335
Mailing Address - Fax:
Practice Address - Street 1:49 W CENTER ST
Practice Address - Street 2:
Practice Address - City:MIDVALE
Practice Address - State:UT
Practice Address - Zip Code:84047-7364
Practice Address - Country:US
Practice Address - Phone:385-887-9002
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-28
Last Update Date:2021-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT12322159-99231223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice