Provider Demographics
NPI:1295979938
Name:REYNOLDS, MARK A (DDS, PHD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:A
Last Name:REYNOLDS
Suffix:
Gender:M
Credentials:DDS, PHD
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 BALTIMORE ST
Mailing Address - Street 2:UMB DENTAL SCHOOL
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21201-1510
Mailing Address - Country:US
Mailing Address - Phone:410-706-7153
Mailing Address - Fax:
Practice Address - Street 1:660 KENILWORTH DR
Practice Address - Street 2:SUITE 103
Practice Address - City:TOWSON
Practice Address - State:MD
Practice Address - Zip Code:21204-2313
Practice Address - Country:US
Practice Address - Phone:410-821-8800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-04-24
Last Update Date:2009-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD91541223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics