Provider Demographics
NPI:1770612715
Name:REEP, NICOLAS KARL (DDS)
Entity type:Individual
Prefix:DR
First Name:NICOLAS
Middle Name:KARL
Last Name:REEP
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 1:3804 KERN WAY
Mailing Address - Street 2:SUITE A
Mailing Address - City:YAKIMA
Mailing Address - State:WA
Mailing Address - Zip Code:98902-6336
Mailing Address - Country:US
Mailing Address - Phone:509-248-0986
Mailing Address - Fax:509-248-1160
Practice Address - Street 1:3804 KERN WAY
Practice Address - Street 2:SUITE A
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98902-6336
Practice Address - Country:US
Practice Address - Phone:509-248-0986
Practice Address - Fax:509-248-1160
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-05
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA101221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5048152Medicaid