Provider Demographics
NPI:1871567016
Name:REYNOLDS, THOMAS JEFFERSON (DMD)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:JEFFERSON
Last Name:REYNOLDS
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1019 PACIFIC AVE STE 300
Mailing Address - Street 2:ATTN: CREDENTIALING
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98402-4488
Mailing Address - Country:US
Mailing Address - Phone:253-597-4550
Mailing Address - Fax:253-597-4556
Practice Address - Street 1:1202 MARTIN LUTHER KING JR WAY
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405-3926
Practice Address - Country:US
Practice Address - Phone:253-441-4743
Practice Address - Fax:253-442-8840
Is Sole Proprietor?:No
Enumeration Date:2006-02-15
Last Update Date:2015-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30022014122300000X
FLDN00000122300000X
WADE60192688122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL076805700Medicaid
OH252130Medicaid