MEDICARE: DR. ELMER LEONARD REAVES JR. 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	1223D0001X	Public Health Dentistry	0401005262	VA

General Provider Information

NPI Number	:	1780674879
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ELMER LEONARD REAVES JR. D.D.S.

Provider Business Mailing Address
First Line	:	1304 BRADDOCK AVE
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23455-4102
Country	:	US
Telephone Number	:	757-363-9568
Fax Number	:

Provider Business Practice Location Address
First Line	:	1320 LASALLE AVE
Second Line	:
City	:	HAMPTON
State	:	VA
Zip	:	23669-3801
Country	:	US
Telephone Number	:	757-727-2585
Fax Number	:	757-727-4881

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

Provider Enumeration Date	:	10/28/2005
Last Update Date	:	07/08/2007

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