Provider Demographics
NPI:1053527812
Name:JEWELL, REGINALD BERNARD (DDS)
Entity type:Individual
Prefix:DR
First Name:REGINALD
Middle Name:BERNARD
Last Name:JEWELL
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 1:19135 GRAND RIVER AVE
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48223-1704
Mailing Address - Country:US
Mailing Address - Phone:313-535-7770
Mailing Address - Fax:
Practice Address - Street 1:19135 GRAND RIVER AVE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48223-1704
Practice Address - Country:US
Practice Address - Phone:313-535-7770
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI173361223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice