Provider Demographics
NPI:1780810853
Name:REAVLEY, BRENTON A (DDS)
Entity type:Individual
Prefix:DR
First Name:BRENTON
Middle Name:A
Last Name:REAVLEY
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 1:4151 N MULBERRY DR
Mailing Address - Street 2:SUITE 230
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64116-4447
Mailing Address - Country:US
Mailing Address - Phone:816-326-8204
Mailing Address - Fax:816-326-8431
Practice Address - Street 1:4151 N MULBERRY DR
Practice Address - Street 2:SUITE 230
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64116-4447
Practice Address - Country:US
Practice Address - Phone:816-326-8204
Practice Address - Fax:816-326-8431
Is Sole Proprietor?:No
Enumeration Date:2009-06-03
Last Update Date:2009-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2007014548122300000X, 1223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics
No122300000XDental ProvidersDentist