Provider Demographics
NPI:1992075972
Name:DR. REYNOLDS COSMETIC DENTAL CENTER
Entity type:Organization
Organization Name:DR. REYNOLDS COSMETIC DENTAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:
Authorized Official - Last Name:REYNOLDS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:708-383-0500
Mailing Address - Street 1:PO BOX 2216
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60303-2216
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-06
Last Update Date:2012-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190177001223G0001X
IL0190286281223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty