MEDICARE: DR MICHAEL L. REYNOLDS DDS INC

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	30146	CA

General Provider Information

NPI Number	:	1417108101
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DR MICHAEL L. REYNOLDS DDS INC

Provider Business Mailing Address
First Line	:	7742 HERSCHEL AVE
Second Line	:	STE. I
City	:	SAN DIEGO
State	:	CA
Zip	:	92037-4444
Country	:	US
Telephone Number	:	858-454-9991
Fax Number	:

Provider Business Practice Location Address
First Line	:	7742 HERSCHEL AVE
Second Line	:	STE. I
City	:	SAN DIEGO
State	:	CA
Zip	:	92037-4444
Country	:	US
Telephone Number	:	858-454-9991
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. MICHAEL L REYNOLDS
Credential	:	DDS
Telephone Number	:	858-454-9991

Provider Enumeration Date	:	10/01/2008
Last Update Date	:	10/01/2008

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