Healthcare Provider Details

I. General information

NPI: 1710106166
Provider Name (Legal Business Name): TRACY R REINER DDS, MS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/24/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

215 WEST HIGHLAND DRIVE, SUITE D
WILLISTON ND
58801
US

IV. Provider business mailing address

215 WEST HIGHLAND DRIVE, SUITE D
WILLISTON ND
58801
US

V. Phone/Fax

Practice location:
  • Phone: 701-572-3414
  • Fax:
Mailing address:
  • Phone: 701-572-3414
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number1800
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: