Provider Demographics
NPI:1932569415
Name:JACK J. REYNOLDS JR. D.D.S., LLC
Entity Type:Organization
Organization Name:JACK J. REYNOLDS JR. D.D.S., LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JACK
Authorized Official - Middle Name:J
Authorized Official - Last Name:REYNOLDS
Authorized Official - Suffix:JR
Authorized Official - Credentials:DDS
Authorized Official - Phone:765-966-7602
Mailing Address - Street 1:1002 OAK DR
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:IN
Mailing Address - Zip Code:47374-1916
Mailing Address - Country:US
Mailing Address - Phone:765-966-7602
Mailing Address - Fax:765-962-1066
Practice Address - Street 1:1002 OAK DR
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:IN
Practice Address - Zip Code:47374-1916
Practice Address - Country:US
Practice Address - Phone:765-966-7602
Practice Address - Fax:765-962-1066
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-26
Last Update Date:2016-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12007171A1223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100255900Medicaid