MEDICARE: DR. JACK THOMAS 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	2016016886	MO

General Provider Information

NPI Number	:	1942651880
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JACK THOMAS REYNOLDS D.D.S.

Provider Business Mailing Address
First Line	:	4100 NE VIVION RD
Second Line	:
City	:	KANSAS CITY
State	:	MO
Zip	:	64119-2811
Country	:	US
Telephone Number	:	816-454-6443
Fax Number	:	816-454-3145

Provider Business Practice Location Address
First Line	:	4100 NE VIVION RD
Second Line	:
City	:	KANSAS CITY
State	:	MO
Zip	:	64119-2811
Country	:	US
Telephone Number	:	816-454-6443
Fax Number	:	816-454-3145

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

Provider Enumeration Date	:	06/22/2016
Last Update Date	:	06/22/2016

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