Healthcare Provider Details

I. General information

NPI: 1376674663
Provider Name (Legal Business Name): KEVIN EDWARD REILLY DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/08/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

650 CHASE PARKWAY
WATERBURY CT
06708
US

IV. Provider business mailing address

650 CHASE PARKWAY
WATERBURY CT
06708
US

V. Phone/Fax

Practice location:
  • Phone: 203-597-8878
  • Fax: 203-597-9722
Mailing address:
  • Phone: 203-597-8878
  • Fax: 203-597-9722

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number6121
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: