Provider Demographics
NPI:1760888028
Name:REITER, MARK EDWARD
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:EDWARD
Last Name:REITER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:717 S STATE ST
Mailing Address - Street 2:SUITE 500
Mailing Address - City:FAIRMONT
Mailing Address - State:MN
Mailing Address - Zip Code:56031-4469
Mailing Address - Country:US
Mailing Address - Phone:507-235-6254
Mailing Address - Fax:504-235-6254
Practice Address - Street 1:717 S STATE ST
Practice Address - Street 2:SUITE 500
Practice Address - City:FAIRMONT
Practice Address - State:MN
Practice Address - Zip Code:56031-4469
Practice Address - Country:US
Practice Address - Phone:507-235-6254
Practice Address - Fax:504-235-6254
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-14
Last Update Date:2014-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN10457122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist