Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122300000X | Dentist | VA6170 | VA |
NPI | 1003974080 |
---|---|
Provider Name | Dr. Kenneth Bradley Reynolds |
First Address | Virginia Beach, VA 23456-6411 |
Second Address | Portsmouth, VA 23707-4011 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 04/12/2006 |
Last Update Date | 08/07/2007 |