Provider Demographics
NPI:1285295279
Name:REEDER, BRYAN D
Entity type:Individual
Prefix:MR
First Name:BRYAN
Middle Name:D
Last Name:REEDER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7890 E FLORENTINE RD
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:86314-1204
Mailing Address - Country:US
Mailing Address - Phone:928-642-9051
Mailing Address - Fax:
Practice Address - Street 1:7890 E FLORENTINE RD
Practice Address - Street 2:
Practice Address - City:PRESCOTT VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:86314-1204
Practice Address - Country:US
Practice Address - Phone:928-642-9051
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-21
Last Update Date:2022-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX352261223G0001X
AZD0116081223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty