Provider Demographics
NPI:1013987627
Name:REAVIS, ALLEN BLEY (DDS)
Entity Type:Individual
Prefix:DR
First Name:ALLEN
Middle Name:BLEY
Last Name:REAVIS
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:PO BOX 399
Mailing Address - Street 2:111 N 5TH
Mailing Address - City:ATCHISON
Mailing Address - State:KS
Mailing Address - Zip Code:66002-0399
Mailing Address - Country:US
Mailing Address - Phone:913-367-0212
Mailing Address - Fax:913-367-6214
Practice Address - Street 1:111 N 5TH ST
Practice Address - Street 2:
Practice Address - City:ATCHISON
Practice Address - State:KS
Practice Address - Zip Code:66002-0399
Practice Address - Country:US
Practice Address - Phone:913-367-0212
Practice Address - Fax:913-367-6214
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS60841223G0001X
MO141041223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS10022285BMedicaid
116750OtherBCBS
KS9176546OtherDORAL MEDICAID