Provider Demographics
NPI:1235120783
Name:REICHARDT, KIRK RUSSELL (DDS)
Entity Type:Individual
Prefix:DR
First Name:KIRK
Middle Name:RUSSELL
Last Name:REICHARDT
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1219 13TH ST
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:NE
Mailing Address - Zip Code:68818-1606
Mailing Address - Country:US
Mailing Address - Phone:407-694-4002
Mailing Address - Fax:402-694-4003
Practice Address - Street 1:1219 13TH ST
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:NE
Practice Address - Zip Code:68818-1606
Practice Address - Country:US
Practice Address - Phone:407-694-4002
Practice Address - Fax:402-694-4003
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-03
Last Update Date:2022-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE6024122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist