MEDICARE: MR. KENNETH DIMAGMALIW REYES DDS

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	1223G0001X	General Practice Dentistry	48173	CA

General Provider Information

NPI Number	:	1194912576
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. KENNETH DIMAGMALIW REYES DDS

Provider Business Mailing Address
First Line	:	PO BOX 5215
Second Line	:
City	:	HERCULES
State	:	CA
Zip	:	94547-5215
Country	:	US
Telephone Number	:	510-323-5002
Fax Number	:

Provider Business Practice Location Address
First Line	:	3980 SAN PABLO DAM RD
Second Line	:	SUITE 202
City	:	EL SOBRANTE
State	:	CA
Zip	:	94803-2840
Country	:	US
Telephone Number	:	510-323-5002
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/28/2007
Last Update Date	:	02/23/2010

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