MEDICARE: INDEPENDENCE DENTAL, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QD0000X	Dental Clinic/Center

General Provider Information

NPI Number	:	1104598721
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INDEPENDENCE DENTAL, LLC

Provider Business Mailing Address
First Line	:	308 N 6TH ST
Second Line	:
City	:	INDEPENDENCE
State	:	KS
Zip	:	67301-3129
Country	:	US
Telephone Number	:	620-331-4499
Fax Number	:

Provider Business Practice Location Address
First Line	:	308 N 6TH ST
Second Line	:
City	:	INDEPENDENCE
State	:	KS
Zip	:	67301-3129
Country	:	US
Telephone Number	:	620-331-4499
Fax Number	:

Authorized Official
Title or Position	:	OWNER/DENTIST
Name	:	DR. JUAN CAMILO REYNOLDS
Credential	:	DDS
Telephone Number	:	918-907-1335

Provider Enumeration Date	:	10/01/2021
Last Update Date	:	10/01/2021

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Directions to “INDEPENDENCE DENTAL, LLC ” Practice Location

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