Provider Demographics
NPI:1386962033
Name:REYNOLDS, RUSSELL T (DDS,MS)
Entity type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:T
Last Name:REYNOLDS
Suffix:
Gender:M
Credentials:DDS,MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:289 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:NH
Mailing Address - Zip Code:03079-2731
Mailing Address - Country:US
Mailing Address - Phone:603-898-9773
Mailing Address - Fax:603-893-5461
Practice Address - Street 1:289 MAIN ST
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:NH
Practice Address - Zip Code:03079-2731
Practice Address - Country:US
Practice Address - Phone:603-898-9773
Practice Address - Fax:603-893-5461
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-05
Last Update Date:2010-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH020931223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH043372433Medicaid