MEDICARE: DR. MILTON BRADFORD REYNOLDS I DDS

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	2784-94	MS

General Provider Information

NPI Number	:	1811169998
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MILTON BRADFORD REYNOLDS I DDS

Provider Business Mailing Address
First Line	:	1336 HIGHWAY 42 EAST
Second Line	:
City	:	PETAL
State	:	MS
Zip	:	39465-9415
Country	:	US
Telephone Number	:	601-450-3371
Fax Number	:	601-450-3373

Provider Business Practice Location Address
First Line	:	1336 HIGHWAY 42 EAST
Second Line	:
City	:	PETAL
State	:	MS
Zip	:	39465-9415
Country	:	US
Telephone Number	:	601-450-3371
Fax Number	:	601-450-3373

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

Provider Enumeration Date	:	03/28/2008
Last Update Date	:	03/28/2008

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