Provider Demographics
NPI:1700025053
Name:REIS, AMY L (DDS)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:L
Last Name:REIS
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1155 CANTERBURY ST
Mailing Address - Street 2:
Mailing Address - City:CRESCO
Mailing Address - State:IA
Mailing Address - Zip Code:52136
Mailing Address - Country:US
Mailing Address - Phone:563-547-1704
Mailing Address - Fax:563-547-1111
Practice Address - Street 1:1155 CANTERBURY ST
Practice Address - Street 2:
Practice Address - City:CRESCO
Practice Address - State:IA
Practice Address - Zip Code:52136
Practice Address - Country:US
Practice Address - Phone:563-547-1704
Practice Address - Fax:563-547-1111
Is Sole Proprietor?:No
Enumeration Date:2009-02-10
Last Update Date:2009-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6148-015122300000X
IA08604122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33813700Medicaid