Provider Demographics
NPI:1811157183
Name:REYNOLDS, KELLY A (DDS)
Entity type:Individual
Prefix:DR
First Name:KELLY
Middle Name:A
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 1:10 AVANTA WAY
Mailing Address - Street 2:SUITE 3
Mailing Address - City:BILLINGS
Mailing Address - State:MT
Mailing Address - Zip Code:59102-6873
Mailing Address - Country:US
Mailing Address - Phone:406-702-1303
Mailing Address - Fax:
Practice Address - Street 1:515 NORTH BROADWAY
Practice Address - Street 2:SUITE 4
Practice Address - City:RED LODGE
Practice Address - State:MT
Practice Address - Zip Code:59068-9255
Practice Address - Country:US
Practice Address - Phone:406-446-2814
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-11
Last Update Date:2017-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT2154122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist