MEDICARE: MR. MICHAEL L REYNOLDS D.D.S.

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	D30146	CA

General Provider Information

NPI Number	:	1578105243
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. MICHAEL L REYNOLDS D.D.S.

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

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

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

Provider Enumeration Date	:	10/14/2019
Last Update Date	:	10/14/2019

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