Provider Demographics
NPI:1194748442
Name:REEVES, JOHN BRECKENRIDGE JR (DMD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:BRECKENRIDGE
Last Name:REEVES
Suffix:JR
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1805 CELANESE RD
Mailing Address - Street 2:PO BOX 2901
Mailing Address - City:ROCK HILL
Mailing Address - State:SC
Mailing Address - Zip Code:29732
Mailing Address - Country:US
Mailing Address - Phone:803-366-4186
Mailing Address - Fax:803-366-4187
Practice Address - Street 1:1805 CELANESE RD
Practice Address - Street 2:
Practice Address - City:ROCK HILL
Practice Address - State:SC
Practice Address - Zip Code:29732
Practice Address - Country:US
Practice Address - Phone:803-366-4186
Practice Address - Fax:803-366-4187
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2291122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC2291Medicaid