Provider Demographics
NPI:1548329386
Name:ODOM, REGINALD (DDS)
Entity type:Individual
Prefix:DR
First Name:REGINALD
Middle Name:
Last Name:ODOM
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:570 E 115TH ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60628-5740
Mailing Address - Country:US
Mailing Address - Phone:773-768-5000
Mailing Address - Fax:
Practice Address - Street 1:4109 W 47TH ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60632-4101
Practice Address - Country:US
Practice Address - Phone:773-847-6740
Practice Address - Fax:773-874-6745
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-07
Last Update Date:2016-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190214711223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice