=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700978079
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ROBERT LANE REEDY DDS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/28/2006
-----------------------------------------------------
Last Update Date | 01/23/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 100 WOLFE NURSERY RD STE 180
-----------------------------------------------------
City | STEPHENVILLE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76401-3731
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 254-965-1931
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 100 WOLFE NURSERY RD STE 180
-----------------------------------------------------
City | STEPHENVILLE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76401-3731
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 254-965-1931
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 14237
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------