Healthcare Provider Details

I. General information

NPI: 1396359980
Provider Name (Legal Business Name): OLIVIA REYES
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/01/2020
Last Update Date: 12/09/2025
Certification Date: 12/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

355 GREENLEAF ST STE E
PARK CITY IL
60085-5708
US

IV. Provider business mailing address

445 E ILLINOIS ST UNIT 4603
CHICAGO IL
60611-5370
US

V. Phone/Fax

Practice location:
  • Phone: 847-249-5700
  • Fax:
Mailing address:
  • Phone: 707-330-5651
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number019.036517
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: