Provider Demographics
NPI:1649293937
Name:REITZEL, JERRY HAROLD (DMD)
Entity type:Individual
Prefix:
First Name:JERRY
Middle Name:HAROLD
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:PO BOX 860
Mailing Address - Street 2:
Mailing Address - City:MAYO
Mailing Address - State:SC
Mailing Address - Zip Code:29368-0860
Mailing Address - Country:US
Mailing Address - Phone:864-578-9040
Mailing Address - Fax:864-578-0539
Practice Address - Street 1:3480 CHESNEE HIGHWAY
Practice Address - Street 2:
Practice Address - City:CHESNEE
Practice Address - State:SC
Practice Address - Zip Code:29323
Practice Address - Country:US
Practice Address - Phone:864-578-9940
Practice Address - Fax:864-578-0539
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC25941223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZZ2594Medicaid