Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223P0700X | Prosthodontist | 047451 | NY |
NPI | 1073749529 |
---|---|
Provider Name | Jeffery Glen Reagan |
First Address | New York, NY 10036-6413 |
Second Address | New York, NY 10036-6413 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 10/06/2009 |
Last Update Date | 22/09/2010 |