Provider Demographics
NPI:1942651880
Name:REYNOLDS, JACK THOMAS (DDS)
Entity Type:Individual
Prefix:DR
First Name:JACK
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 1:4100 NE VIVION RD
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64119-2811
Mailing Address - Country:US
Mailing Address - Phone:816-454-6443
Mailing Address - Fax:816-454-3145
Practice Address - Street 1:4100 NE VIVION RD
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64119-2811
Practice Address - Country:US
Practice Address - Phone:816-454-6443
Practice Address - Fax:816-454-3145
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-22
Last Update Date:2016-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20160168861223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice