Provider Demographics
NPI:1336277656
Name:REID, DERRICK (DDS)
Entity Type:Individual
Prefix:DR
First Name:DERRICK
Middle Name:
Last Name:REID
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:54310 MYSTIQUE CT
Mailing Address - Street 2:
Mailing Address - City:MISHAWAKA
Mailing Address - State:IN
Mailing Address - Zip Code:46545-1824
Mailing Address - Country:US
Mailing Address - Phone:615-327-9400
Mailing Address - Fax:
Practice Address - Street 1:54310 MYSTIQUE CT
Practice Address - Street 2:
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46545-1824
Practice Address - Country:US
Practice Address - Phone:615-327-9400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-28
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN81591223G0001X
IN12012614A1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice