MEDICARE: DR. STEPHEN ALEXANDER RELLER DMD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	DE61315076	WA
2	390200000X	Student in an Organized Health Care Education/Training Program		OR
3	122300000X	Dentist	D10682	OR

General Provider Information

NPI Number	:	1538697974
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. STEPHEN ALEXANDER RELLER DMD

Provider Business Mailing Address
First Line	:	19111 NE 24TH ST
Second Line	:
City	:	VANCOUVER
State	:	WA
Zip	:	98684-1818
Country	:	US
Telephone Number	:	503-477-1897
Fax Number	:

Provider Business Practice Location Address
First Line	:	16703 SE MCGILLIVRAY BLVD STE 100
Second Line	:
City	:	VANCOUVER
State	:	WA
Zip	:	98683-3418
Country	:	US
Telephone Number	:	503-477-1897
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/30/2017
Last Update Date	:	09/06/2022

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