Healthcare Provider Details

I. General information

NPI: 1467540393
Provider Name (Legal Business Name): MARK GEORGE REITZ D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/10/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 E BROAD ST
BLACKSTONE VA
23824-1815
US

IV. Provider business mailing address

103 E BROAD ST
BLACKSTONE VA
23824-1815
US

V. Phone/Fax

Practice location:
  • Phone: 434-292-5318
  • Fax:
Mailing address:
  • Phone: 434-292-5318
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number05302
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: