MEDICARE: WILLIS EDWARD REESE 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	DS4364	TN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	3044538	OTHER	TN	BCBST PROVIDER NUMBER

General Provider Information

NPI Number	:	1952431736
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	WILLIS EDWARD REESE DDS

Provider Business Mailing Address
First Line	:	626 E REELFOOT AVE
Second Line	:
City	:	UNION CITY
State	:	TN
Zip	:	38261-5739
Country	:	US
Telephone Number	:	731-885-3561
Fax Number	:	731-885-3097

Provider Business Practice Location Address
First Line	:	626 E REELFOOT AVE
Second Line	:
City	:	UNION CITY
State	:	TN
Zip	:	38261-5739
Country	:	US
Telephone Number	:	731-885-3561
Fax Number	:	731-885-3097

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

Provider Enumeration Date	:	03/07/2007
Last Update Date	:	07/08/2007

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