Provider Demographics
NPI:1336246057
Name:REARDON, JOHN FORAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:FORAN
Last Name:REARDON
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 1:333 MAIN ST N
Mailing Address - Street 2:SUITE 111
Mailing Address - City:STILLWATER
Mailing Address - State:MN
Mailing Address - Zip Code:55082-5098
Mailing Address - Country:US
Mailing Address - Phone:651-439-6125
Mailing Address - Fax:651-439-0038
Practice Address - Street 1:333 MAIN ST N
Practice Address - Street 2:SUITE 111
Practice Address - City:STILLWATER
Practice Address - State:MN
Practice Address - Zip Code:55082-5098
Practice Address - Country:US
Practice Address - Phone:651-439-6125
Practice Address - Fax:651-439-0038
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND110191223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice