Provider Demographics
NPI:1801053475
Name:ROGER N REYNOLDS 111 DDS MS PA
Entity type:Organization
Organization Name:ROGER N REYNOLDS 111 DDS MS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:NIXON
Authorized Official - Last Name:REYNOLDS
Authorized Official - Suffix:III
Authorized Official - Credentials:DDS
Authorized Official - Phone:336-768-9010
Mailing Address - Street 1:3809 FORRESTGATE DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-2982
Mailing Address - Country:US
Mailing Address - Phone:336-768-9010
Mailing Address - Fax:336-768-9011
Practice Address - Street 1:3809 FORRESTGATE DR
Practice Address - Street 2:SUITE A
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-2982
Practice Address - Country:US
Practice Address - Phone:336-768-9010
Practice Address - Fax:336-768-9011
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-20
Last Update Date:2008-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3599261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental