Healthcare Provider Details

I. General information

NPI: 1023003183
Provider Name (Legal Business Name): TERESA ELLEN REEVES DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/15/2005
Last Update Date: 11/15/2021
Certification Date: 10/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

60 MDG/SGDD 101 BODIN CIRCLE, TRAVIS AFB
TRAVIS AFB CA
94535
US

IV. Provider business mailing address

60 MDG/SGDD 101 BODIN CIRCLE, TRAVIS AFB
TRAVIS AFB CA
94535
US

V. Phone/Fax

Practice location:
  • Phone: 707-423-7008
  • Fax:
Mailing address:
  • Phone: 707-423-7008
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number17112
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code1223X0008X
TaxonomyOral and Maxillofacial Radiology Dentistry
License Number17112
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: