MEDICARE: REAVLEY DENTAL

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	:	1447919840
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	REAVLEY DENTAL

Provider Business Mailing Address
First Line	:	804 GULF STREET
Second Line	:
City	:	LAMAR
State	:	MO
Zip	:	64759
Country	:	US
Telephone Number	:	417-682-3393
Fax Number	:	417-683-6659

Provider Business Practice Location Address
First Line	:	804 GULF STREET
Second Line	:
City	:	LAMAR
State	:	MO
Zip	:	64759-6475
Country	:	US
Telephone Number	:	417-682-3393
Fax Number	:	417-682-6659

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	MS. CAROL D REAVLEY
Credential	:
Telephone Number	:	417-682-3393

Provider Enumeration Date	:	12/13/2021
Last Update Date	:	12/21/2021

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1760487201 — GERALD B. SWEARINGEN OD
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Directions to “REAVLEY DENTAL ” Practice Location

Language	Start Address	Practice Location

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