Healthcare Provider Details

I. General information

NPI: 1164977948
Provider Name (Legal Business Name): ADAM REYNOLDS DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/22/2016
Last Update Date: 08/24/2023
Certification Date: 08/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 HUGHES RD
MADISON AL
35758-2238
US

IV. Provider business mailing address

25 HUGHES RD
MADISON AL
35758-2238
US

V. Phone/Fax

Practice location:
  • Phone: 256-870-8700
  • Fax: 256-870-0171
Mailing address:
  • Phone: 606-207-2780
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number2014006033
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: