Healthcare Provider Details

I. General information

NPI: 1386962033
Provider Name (Legal Business Name): RUSSELL T. REYNOLDS DDS,MS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/05/2010
Last Update Date: 05/05/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

289 MAIN ST
SALEM NH
03079-2731
US

IV. Provider business mailing address

289 MAIN ST
SALEM NH
03079-2731
US

V. Phone/Fax

Practice location:
  • Phone: 603-898-9773
  • Fax: 603-893-5461
Mailing address:
  • Phone: 603-898-9773
  • Fax: 603-893-5461

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number02093
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: