MEDICARE: REAVES DENTAL PRACTICE, PLLC

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	032955	NY
2	261QD0000X	Dental Clinic/Center	053015	NY

General Provider Information

NPI Number	:	1124264866
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	REAVES DENTAL PRACTICE, PLLC

Provider Business Mailing Address
First Line	:	4301 MIDDLE SETTLEMENT RD
Second Line	:
City	:	NEW HARTFORD
State	:	NY
Zip	:	13413-5317
Country	:	US
Telephone Number	:	315-736-0139
Fax Number	:	315-768-6148

Provider Business Practice Location Address
First Line	:	4301 MIDDLE SETTLEMENT RD
Second Line	:
City	:	NEW HARTFORD
State	:	NY
Zip	:	13413-5317
Country	:	US
Telephone Number	:	315-736-0139
Fax Number	:	315-768-6148

Authorized Official
Title or Position	:	OWNER - GENERAL DENTIST
Name	:	DR. JUSTIN J REAVES
Credential	:	DDS
Telephone Number	:	315-736-0139

Provider Enumeration Date	:	12/31/2008
Last Update Date	:	11/05/2014

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