=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649293937
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JERRY HAROLD REITZEL DMD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/26/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3480 CHESNEE HIGHWAY
-----------------------------------------------------
City | CHESNEE
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29323
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 864-578-9940
-----------------------------------------------------
Fax | 864-578-0539
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 860
-----------------------------------------------------
City | MAYO
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29368-0860
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 864-578-9040
-----------------------------------------------------
Fax | 864-578-0539
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 2594
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------