Healthcare Provider Details

I. General information

NPI: 1134265275
Provider Name (Legal Business Name): RANDY REASCH DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/29/2007
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2121 WEST RESERVATION LOOP ROAD
CAMP VERDE AZ
86322-8412
US

IV. Provider business mailing address

PO BOX 31001-0698
PASADENA CA
91110-0698
US

V. Phone/Fax

Practice location:
  • Phone: 928-567-2168
  • Fax:
Mailing address:
  • Phone: 602-263-1200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number4431
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: