Provider Demographics
NPI:1801503107
Name:REILLY, DYLAN ANTHONY
Entity type:Individual
Prefix:
First Name:DYLAN
Middle Name:ANTHONY
Last Name:REILLY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 BERNARD ST
Mailing Address - Street 2:
Mailing Address - City:LAWRENCE
Mailing Address - State:NY
Mailing Address - Zip Code:11559-1245
Mailing Address - Country:US
Mailing Address - Phone:516-492-5344
Mailing Address - Fax:
Practice Address - Street 1:16 BERNARD ST
Practice Address - Street 2:
Practice Address - City:LAWRENCE
Practice Address - State:NY
Practice Address - Zip Code:11559-1245
Practice Address - Country:US
Practice Address - Phone:516-492-5344
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-04
Last Update Date:2022-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer