Healthcare Provider Details

I. General information

NPI: 1235120783
Provider Name (Legal Business Name): KIRK RUSSELL REICHARDT DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/03/2005
Last Update Date: 01/28/2022
Certification Date: 01/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1219 13TH ST
AURORA NE
68818-1606
US

IV. Provider business mailing address

1219 13TH ST
AURORA NE
68818-1606
US

V. Phone/Fax

Practice location:
  • Phone: 407-694-4002
  • Fax: 402-694-4003
Mailing address:
  • Phone: 407-694-4002
  • Fax: 402-694-4003

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number6024
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: