Provider Demographics
NPI:1972347631
Name:REDDEN, REILLY KELLEY (DMD)
Entity type:Individual
Prefix:
First Name:REILLY
Middle Name:KELLEY
Last Name:REDDEN
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:REILLY
Other - Middle Name:GRAY
Other - Last Name:KELLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:133 CALLEN DR
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29607-6182
Mailing Address - Country:US
Mailing Address - Phone:864-449-1830
Mailing Address - Fax:
Practice Address - Street 1:1405 BRUSHY CREEK RD
Practice Address - Street 2:
Practice Address - City:TAYLORS
Practice Address - State:SC
Practice Address - Zip Code:29687-4008
Practice Address - Country:US
Practice Address - Phone:864-244-3132
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-19
Last Update Date:2024-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCDGD.108471223G0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice