Provider Demographics
NPI:1336246248
Name:REILLY, TERRENCE (DMD)
Entity Type:Individual
Prefix:DR
First Name:TERRENCE
Middle Name:
Last Name:REILLY
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1009 GLOUSMAN RD
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27104-1275
Mailing Address - Country:US
Mailing Address - Phone:336-760-3095
Mailing Address - Fax:
Practice Address - Street 1:201 CHARLOIS BLVD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-1507
Practice Address - Country:US
Practice Address - Phone:336-718-1800
Practice Address - Fax:336-718-1915
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC45871223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice