Provider Demographics
NPI:1295947463
Name:RIETZ DENTAL MANAGEMENT CORPORATION
Entity type:Organization
Organization Name:RIETZ DENTAL MANAGEMENT CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:W
Authorized Official - Last Name:RIETZ
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:509-522-0499
Mailing Address - Street 1:208 SOUTH PARK ST
Mailing Address - Street 2:
Mailing Address - City:WALLA WALLA
Mailing Address - State:WA
Mailing Address - Zip Code:99362-3247
Mailing Address - Country:US
Mailing Address - Phone:509-522-0499
Mailing Address - Fax:509-522-0593
Practice Address - Street 1:208 SOUTH PARK ST
Practice Address - Street 2:
Practice Address - City:WALLA WALLA
Practice Address - State:WA
Practice Address - Zip Code:99362-3247
Practice Address - Country:US
Practice Address - Phone:509-522-0499
Practice Address - Fax:509-522-0593
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE000065301223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA56530OtherWASHINGTON DENTAL SVC
WAUNTITED CONCORDIAOther00762606
WA5017033Medicaid
WAUNTITED CONCORDIAOther00762606