Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223E0200X | Endodontist | D8074 | OR |
NPI | 1134382344 |
---|---|
Provider Name | Dr. Russell Kai Reynolds |
First Address | Ashland, OR 97520-2232 |
Second Address | Ashland, OR 97520-2232 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 08/07/2008 |
Last Update Date | 08/07/2008 |