Provider Demographics
NPI:1023597192
Name:REYNOLDS, STEPHANIE MARIE (RDH)
Entity type:Individual
Prefix:MS
First Name:STEPHANIE
Middle Name:MARIE
Last Name:REYNOLDS
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6933 EXNER RD
Mailing Address - Street 2:
Mailing Address - City:DARIEN
Mailing Address - State:IL
Mailing Address - Zip Code:60561-3693
Mailing Address - Country:US
Mailing Address - Phone:630-632-1814
Mailing Address - Fax:
Practice Address - Street 1:2 E 22ND ST STE 201
Practice Address - Street 2:
Practice Address - City:LOMBARD
Practice Address - State:IL
Practice Address - Zip Code:60148-6105
Practice Address - Country:US
Practice Address - Phone:630-627-4680
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-09
Last Update Date:2018-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL020016257124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist