Healthcare Provider Details

I. General information

NPI: 1558748434
Provider Name (Legal Business Name): STACEY M REISS DDS, MDENTSC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/30/2015
Last Update Date: 04/17/2020
Certification Date: 04/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2800 COORS BLVD NW STE A
ALBUQUERQUE NM
87120-1204
US

IV. Provider business mailing address

5110 EAKES RD NW
LOS RANCHOS NM
87107-5538
US

V. Phone/Fax

Practice location:
  • Phone: 505-352-1166
  • Fax:
Mailing address:
  • Phone: 203-247-1456
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberDD4909
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: