Provider Demographics
NPI:1922451335
Name:REYNOLDS, MARYBETH BLAIR (DMD)
Entity Type:Individual
Prefix:
First Name:MARYBETH
Middle Name:BLAIR
Last Name:REYNOLDS
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 1:425 MAPLE AVE
Mailing Address - Street 2:
Mailing Address - City:OWENSBORO
Mailing Address - State:KY
Mailing Address - Zip Code:42301-5085
Mailing Address - Country:US
Mailing Address - Phone:270-570-4804
Mailing Address - Fax:
Practice Address - Street 1:3723 S GRIFFITH AVE
Practice Address - Street 2:
Practice Address - City:OWENSBORO
Practice Address - State:KY
Practice Address - Zip Code:42301-6950
Practice Address - Country:US
Practice Address - Phone:270-926-3722
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-20
Last Update Date:2024-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN 22178122300000X
KY106811223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist