Provider Demographics
NPI:1447919840
Name:REAVLEY DENTAL
Entity type:Organization
Organization Name:REAVLEY DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:D
Authorized Official - Last Name:REAVLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:417-682-3393
Mailing Address - Street 1:804 GULF STREET
Mailing Address - Street 2:
Mailing Address - City:LAMAR
Mailing Address - State:MO
Mailing Address - Zip Code:64759
Mailing Address - Country:US
Mailing Address - Phone:417-682-3393
Mailing Address - Fax:417-683-6659
Practice Address - Street 1:804 GULF STREET
Practice Address - Street 2:
Practice Address - City:LAMAR
Practice Address - State:MO
Practice Address - Zip Code:64759-6475
Practice Address - Country:US
Practice Address - Phone:417-682-3393
Practice Address - Fax:417-682-6659
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-12-13
Last Update Date:2021-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental