Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122300000X | Dentist | DL12552 | MA |
NPI | 1003299454 |
---|---|
Provider Name | Dr. Jeffrey Brian Reardon |
First Address | Boston, MA 02115-5724 |
Second Address | Boston, MA 02115-5724 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 02/07/2015 |
Last Update Date | 02/07/2015 |