Provider Demographics
NPI:1538697974
Name:RELLER, STEPHEN ALEXANDER (DMD)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:ALEXANDER
Last Name:RELLER
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 1:19111 NE 24TH ST
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98684-1818
Mailing Address - Country:US
Mailing Address - Phone:503-477-1897
Mailing Address - Fax:
Practice Address - Street 1:16703 SE MCGILLIVRAY BLVD STE 100
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98683-3418
Practice Address - Country:US
Practice Address - Phone:503-477-1897
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-30
Last Update Date:2022-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE61315076122300000X
OR390200000X
ORD10682122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program