Provider Demographics
NPI:1871682906
Name:REITZEL, JEFFREY DAMON (DMD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:DAMON
Last Name:REITZEL
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 1:200 5TH AVE
Mailing Address - Street 2:3RD FLOOR
Mailing Address - City:WALTHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02451-8779
Mailing Address - Country:US
Mailing Address - Phone:781-647-0772
Mailing Address - Fax:
Practice Address - Street 1:200 5TH AVE
Practice Address - Street 2:3RD FLOOR
Practice Address - City:WALTHAM
Practice Address - State:MA
Practice Address - Zip Code:02451-8779
Practice Address - Country:US
Practice Address - Phone:781-647-0772
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2014-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4214122300000X
MADN18559191223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZX4214Medicaid