Provider Demographics
NPI:1841455615
Name:JACK K. REYNOLDS DDS PA
Entity type:Organization
Organization Name:JACK K. REYNOLDS DDS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:D.D.S
Authorized Official - Prefix:DR
Authorized Official - First Name:SHARON
Authorized Official - Middle Name:ELAINE
Authorized Official - Last Name:REYNOLDS LUNDGREN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-676-5252
Mailing Address - Street 1:PO BOX 696
Mailing Address - Street 2:
Mailing Address - City:EDGEWOOD
Mailing Address - State:MD
Mailing Address - Zip Code:21040-0696
Mailing Address - Country:US
Mailing Address - Phone:410-676-5252
Mailing Address - Fax:410-679-4068
Practice Address - Street 1:2104 TRIMBLE RD
Practice Address - Street 2:
Practice Address - City:EDGEWOOD
Practice Address - State:MD
Practice Address - Zip Code:21040-3126
Practice Address - Country:US
Practice Address - Phone:410-676-5252
Practice Address - Fax:410-679-4068
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-22
Last Update Date:2008-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
No204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD817292OtherUNITED CONCORDIA