Provider Demographics
NPI:1225020548
Name:REAKSECKER, MARK NOBLE FRED (DMD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:NOBLE FRED
Last Name:REAKSECKER
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15230 SE 82ND DR
Mailing Address - Street 2:
Mailing Address - City:CLACKAMAS
Mailing Address - State:OR
Mailing Address - Zip Code:97015-9606
Mailing Address - Country:US
Mailing Address - Phone:503-655-9000
Mailing Address - Fax:
Practice Address - Street 1:15230 SE 82ND DR
Practice Address - Street 2:
Practice Address - City:CLACKAMAS
Practice Address - State:OR
Practice Address - Zip Code:97015-9606
Practice Address - Country:US
Practice Address - Phone:503-655-9000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-23
Last Update Date:2009-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD65021223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice