MEDICARE: DR. DOUGLAS W RIETZ D.M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	DE00006530	WA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	56530	OTHER	WA	WASHINGTON DENTAL SVC
2	00762606	OTHER	WA	UNITED CONCORDIA
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1265501233
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DOUGLAS W RIETZ D.M.D.

Provider Business Mailing Address
First Line	:	208 S PARK ST
Second Line	:
City	:	WALLA WALLA
State	:	WA
Zip	:	99362-3247
Country	:	US
Telephone Number	:	509-522-0499
Fax Number	:	509-522-0593

Provider Business Practice Location Address
First Line	:	208 S PARK ST
Second Line	:
City	:	WALLA WALLA
State	:	WA
Zip	:	99362-3247
Country	:	US
Telephone Number	:	509-522-0499
Fax Number	:	509-522-0593

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/06/2006
Last Update Date	:	07/08/2007

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