Healthcare Provider Details

I. General information

NPI: 1619265964
Provider Name (Legal Business Name): BRIAN A REAVLEY DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/20/2011
Last Update Date: 09/07/2021
Certification Date: 09/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

804 GULF ST
LAMAR MO
64759-1239
US

IV. Provider business mailing address

804 GULF ST
LAMAR MO
64759-1239
US

V. Phone/Fax

Practice location:
  • Phone: 174-682-3393
  • Fax: 417-682-6659
Mailing address:
  • Phone: 417-682-3393
  • Fax: 417-682-6659

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number2011016310
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: