MEDICARE: MICHAEL JOSEPH REIDER D.D.S.

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	1223G0001X	General Practice Dentistry	12012309A	IN

General Provider Information

NPI Number	:	1780063446
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHAEL JOSEPH REIDER D.D.S.

Provider Business Mailing Address
First Line	:	51281 ASHLEY DR
Second Line	:
City	:	GRANGER
State	:	IN
Zip	:	46530-8841
Country	:	US
Telephone Number	:	219-363-9838
Fax Number	:

Provider Business Practice Location Address
First Line	:	423 WATERFALL DR
Second Line	:
City	:	ELKHART
State	:	IN
Zip	:	46516-3660
Country	:	US
Telephone Number	:	574-522-8578
Fax Number	:

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

Provider Enumeration Date	:	05/27/2015
Last Update Date	:	05/27/2015

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