Provider Demographics
NPI:1558748434
Name:REISS, STACEY M (DDS, MDENTSC)
Entity Type:Individual
Prefix:DR
First Name:STACEY
Middle Name:M
Last Name:REISS
Suffix:
Gender:F
Credentials:DDS, MDENTSC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5110 EAKES RD NW
Mailing Address - Street 2:
Mailing Address - City:LOS RANCHOS
Mailing Address - State:NM
Mailing Address - Zip Code:87107-5538
Mailing Address - Country:US
Mailing Address - Phone:203-247-1456
Mailing Address - Fax:
Practice Address - Street 1:2800 COORS BLVD NW STE A
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87120-1204
Practice Address - Country:US
Practice Address - Phone:505-352-1166
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-30
Last Update Date:2020-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD49091223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics