Provider Demographics
NPI:1801309828
Name:REYES, JUSTIN ROSS (RDH)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:ROSS
Last Name:REYES
Suffix:
Gender:M
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6340 CAPULINA AVE APT 3D
Mailing Address - Street 2:
Mailing Address - City:MORTON GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60053-2896
Mailing Address - Country:US
Mailing Address - Phone:312-487-6668
Mailing Address - Fax:
Practice Address - Street 1:1015 W LAWRENCE AVE FL 2
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60640-5017
Practice Address - Country:US
Practice Address - Phone:773-275-2586
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-13
Last Update Date:2017-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL020.014285124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes124Q00000XDental ProvidersDental HygienistGroup - Single Specialty