Healthcare Provider Details

I. General information

NPI: 1700960077
Provider Name (Legal Business Name): JERRY W REASNER DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/24/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

924 MONTCLAIR ROAD SUITE 101
BIRMINGHAM AL
35213
US

IV. Provider business mailing address

924 MONTCLAIR ROAD SUITE 101
BIRMINGHAM AL
35213
US

V. Phone/Fax

Practice location:
  • Phone: 205-595-2626
  • Fax: 205-592-9241
Mailing address:
  • Phone: 205-595-2626
  • Fax: 205-592-9241

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number4009
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: