Provider Demographics
NPI:1366465882
Name:RIEDERER, MARK S (DDS)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:S
Last Name:RIEDERER
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 1:9309 GLACIER HWY
Mailing Address - Street 2:B-105
Mailing Address - City:JUNEAU
Mailing Address - State:AK
Mailing Address - Zip Code:99801-9306
Mailing Address - Country:US
Mailing Address - Phone:907-789-3100
Mailing Address - Fax:907-789-3119
Practice Address - Street 1:9309 GLACIER HWY
Practice Address - Street 2:B-105
Practice Address - City:JUNEAU
Practice Address - State:AK
Practice Address - Zip Code:99801-9306
Practice Address - Country:US
Practice Address - Phone:907-789-3100
Practice Address - Fax:907-789-3119
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-25
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AKAA6511223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKDD6510Medicaid