Provider Demographics
NPI:1699974279
Name:REYNOLDS, PAMELA JEAN (DDS)
Entity type:Individual
Prefix:DR
First Name:PAMELA
Middle Name:JEAN
Last Name:REYNOLDS
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 MADISON ST
Mailing Address - Street 2:SUITE 301
Mailing Address - City:OAK PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60302-4278
Mailing Address - Country:US
Mailing Address - Phone:708-383-0500
Mailing Address - Fax:708-383-0800
Practice Address - Street 1:101 MADISON ST
Practice Address - Street 2:SUITE 301
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60302-4278
Practice Address - Country:US
Practice Address - Phone:708-383-0500
Practice Address - Fax:708-383-0800
Is Sole Proprietor?:No
Enumeration Date:2007-07-13
Last Update Date:2023-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190177001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL113719151OtherEIN