Healthcare Provider Details

I. General information

NPI: 1861693491
Provider Name (Legal Business Name): BRYAN MARK RECKER D.D.S., M.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/30/2007
Last Update Date: 06/24/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2112 VIKING DR NW
ROCHESTER MN
55901-3522
US

IV. Provider business mailing address

2112 VIKING DR NW
ROCHESTER MN
55901-3522
US

V. Phone/Fax

Practice location:
  • Phone: 507-208-9124
  • Fax: 507-218-0326
Mailing address:
  • Phone: 507-208-9124
  • Fax: 507-218-0326

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License NumberD12733
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number08416
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: