Healthcare Provider Details

I. General information

NPI: 1104264985
Provider Name (Legal Business Name): REEVES, D.D.S. AND LAVALLEY, D.D.S., A DENTAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/13/2013
Last Update Date: 02/09/2023
Certification Date: 02/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3485 BROOKSIDE RD STE 101
STOCKTON CA
95219-1757
US

IV. Provider business mailing address

3100 ZINFANDEL DR STE 400
RANCHO CORDOVA CA
95670-6391
US

V. Phone/Fax

Practice location:
  • Phone: 209-957-4386
  • Fax:
Mailing address:
  • Phone: 916-570-1500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DEREK BOYES
Title or Position: COO
Credential:
Phone: 916-570-1500