Basic Information
| Provider Information | |||||||||
| NPI: | 1871567016 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | REYNOLDS | ||||||||
| FirstName: | THOMAS | ||||||||
| MiddleName: | JEFFERSON | ||||||||
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| Credential: | DMD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1019 PACIFIC AVE STE 300 | ||||||||
| Address2: | ATTN: CREDENTIALING | ||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984024488 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2535974550 | ||||||||
| FaxNumber: | 2535974556 | ||||||||
| Practice Location | |||||||||
| Address1: | 1202 MARTIN LUTHER KING JR WAY | ||||||||
| Address2: | |||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984053926 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2534414743 | ||||||||
| FaxNumber: | 2534428840 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/15/2006 | ||||||||
| LastUpdateDate: | 11/12/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 30022014 | OH | N | Dental Providers | Dentist | 122300000X | DN00000 | FL | N | Dental Providers | Dentist | 122300000X | DE60192688 | WA | Y | Dental Providers | Dentist |
ID Information
| ID | Type | State | Issuer | Description | 076805700 | 05 | FL | MEDICAID | 252130 | 05 | OH | MEDICAID |