MEDICARE: ROGER N REYNOLDS 111 DDS MS PA

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	3599	NC

General Provider Information

NPI Number	:	1801053475
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ROGER N REYNOLDS 111 DDS MS PA

Provider Business Mailing Address
First Line	:	3809 FORRESTGATE DR
Second Line	:	SUITE A
City	:	WINSTON SALEM
State	:	NC
Zip	:	27103-2982
Country	:	US
Telephone Number	:	336-768-9010
Fax Number	:	336-768-9011

Provider Business Practice Location Address
First Line	:	3809 FORRESTGATE DR
Second Line	:	SUITE A
City	:	WINSTON SALEM
State	:	NC
Zip	:	27103-2982
Country	:	US
Telephone Number	:	336-768-9010
Fax Number	:	336-768-9011

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. ROGER NIXON REYNOLDS III
Credential	:	DDS
Telephone Number	:	336-768-9010

Provider Enumeration Date	:	05/20/2008
Last Update Date	:	05/20/2008

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