Healthcare Provider Details

I. General information

NPI: 1841455615
Provider Name (Legal Business Name): JACK K. REYNOLDS DDS PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/22/2008
Last Update Date: 07/22/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2104 TRIMBLE RD
EDGEWOOD MD
21040-3126
US

IV. Provider business mailing address

PO BOX 696
EDGEWOOD MD
21040-0696
US

V. Phone/Fax

Practice location:
  • Phone: 410-676-5252
  • Fax: 410-679-4068
Mailing address:
  • Phone: 410-676-5252
  • Fax: 410-679-4068

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number
License Number State

VIII. Authorized Official

Name: DR. SHARON ELAINE REYNOLDS LUNDGREN
Title or Position: D.D.S
Credential:
Phone: 410-676-5252