1003974080 NPI number — DR. KENNETH BRADLEY REYNOLDS D.D.S

Table of content: DR. KENNETH BRADLEY REYNOLDS D.D.S (NPI 1003974080)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003974080 NPI number — DR. KENNETH BRADLEY REYNOLDS D.D.S

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
REYNOLDS
Provider First Name:
KENNETH
Provider Middle Name:
BRADLEY
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.D.S
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1003974080
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
788 LOS COLONIS DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
VIRGINIA BEACH
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
23456-6411
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
757-477-5051
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1307 AIRLINE BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PORTSMOUTH
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23707-4011
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
757-399-4662
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/04/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  VA6170 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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