MEDICARE: JUAN CAMILO REYNOLDS 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	12322159-9923	UT

General Provider Information

NPI Number	:	1891468641
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JUAN CAMILO REYNOLDS DDS

Provider Business Mailing Address
First Line	:	650 W SOUTH TEMPLE APT C108
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84104-1041
Country	:	US
Telephone Number	:	918-907-1335
Fax Number	:

Provider Business Practice Location Address
First Line	:	49 W CENTER ST
Second Line	:
City	:	MIDVALE
State	:	UT
Zip	:	84047-7364
Country	:	US
Telephone Number	:	385-887-9002
Fax Number	:

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

Provider Enumeration Date	:	07/28/2021
Last Update Date	:	07/28/2021

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