Healthcare Provider Details

I. General information

NPI: 1437609260
Provider Name (Legal Business Name): NATHAN EDWARD RIECK DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/05/2016
Last Update Date: 06/11/2020
Certification Date: 06/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7686 W RIDGE RD
FAIRVIEW PA
16415-1074
US

IV. Provider business mailing address

204 W PLUM ST
EDINBORO PA
16412-6002
US

V. Phone/Fax

Practice location:
  • Phone: 814-474-5022
  • Fax: 814-474-5022
Mailing address:
  • Phone: 814-734-4451
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDS041333
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: