Provider Demographics
NPI:1649435116
Name:REYNOLDS DENTAL PRACTICE
Entity type:Organization
Organization Name:REYNOLDS DENTAL PRACTICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RANDALL
Authorized Official - Middle Name:KERMIT
Authorized Official - Last Name:REYNOLDS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:601-469-4881
Mailing Address - Street 1:208 W THIRD ST
Mailing Address - Street 2:
Mailing Address - City:FOREST
Mailing Address - State:MS
Mailing Address - Zip Code:39074-4106
Mailing Address - Country:US
Mailing Address - Phone:601-469-4881
Mailing Address - Fax:601-469-3436
Practice Address - Street 1:208 W THIRD ST
Practice Address - Street 2:
Practice Address - City:FOREST
Practice Address - State:MS
Practice Address - Zip Code:39074-4106
Practice Address - Country:US
Practice Address - Phone:601-469-4881
Practice Address - Fax:601-469-3436
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-24
Last Update Date:2010-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty