Provider Demographics
NPI:1437179140
Name:REIFEIS, ROBERT L JR (DDS)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:L
Last Name:REIFEIS
Suffix:JR
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 1:16136 COLDWATER RD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-9708
Mailing Address - Country:US
Mailing Address - Phone:260-602-6454
Mailing Address - Fax:
Practice Address - Street 1:3303 TRIER RD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46815-4768
Practice Address - Country:US
Practice Address - Phone:260-999-4929
Practice Address - Fax:260-755-1086
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2023-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12009415A1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000379003OtherBCBS/ANTHEM
IN12009415AOtherINDIANA PROFESSIONAL LICENSING AGENCY
IN924690EMedicare ID - Type Unspecified
IN200541530Medicaid