Provider Demographics
NPI:1528076593
Name:REYNOLDS, EDWARD JR (DDS)
Entity type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:
Last Name:REYNOLDS
Suffix:JR
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:47 TOWN ST
Mailing Address - Street 2:NORWICH
Mailing Address - City:NORWICH
Mailing Address - State:CT
Mailing Address - Zip Code:06360-2315
Mailing Address - Country:US
Mailing Address - Phone:860-892-7042
Mailing Address - Fax:860-823-3060
Practice Address - Street 1:47 TOWN ST
Practice Address - Street 2:
Practice Address - City:NORWICH
Practice Address - State:CT
Practice Address - Zip Code:06360-2315
Practice Address - Country:US
Practice Address - Phone:860-892-7042
Practice Address - Fax:860-823-3060
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2013-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT45441223S0112X
CT045441223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008032342Medicaid
CT190000432Medicare ID - Type Unspecified
T22147Medicare UPIN