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General NPI Number Information
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NPI Number | 1063615342
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Entity Type | Organization
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Legal Business Name | REILLY FAMILY DENTAL LLC
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Dates
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Enumeration Date | 06/06/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 1018 KING RD
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City | TOMAHAWK
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State | WI
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Zip | 54487
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Country | US
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Telephone | 715-453-7071
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Fax | 715-453-9461
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Provider Business Mailing Address
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Address Line | PO BOX 287
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City | TOMAHAWK
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State | WI
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Zip | 54487
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Country | US
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Telephone | 715-453-7071
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Fax | 715-453-9461
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Authorized Official
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Title or Position | DENTIST OWNER
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Name | DR. DEWEY IRVING REILLY
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Credential | DDS
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Telephone | 715-453-7071
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 5001190015
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License Number State | WI
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Taxonomy #2
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 6009015
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License Number State | WI
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Taxonomy #3
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 5005793
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License Number State | WI
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