Healthcare Provider Details

I. General information

NPI: 1720209679
Provider Name (Legal Business Name): MRS. KIM REIDENBAUGH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 S BROAD ST
LITITZ PA
17543-1402
US

IV. Provider business mailing address

31 ROYAL DR
LITITZ PA
17543-8220
US

V. Phone/Fax

Practice location:
  • Phone: 717-626-2355
  • Fax:
Mailing address:
  • Phone: 717-626-2355
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code126800000X
TaxonomyDental Assistant
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: