Provider Demographics
NPI:1811064231
Name:DR STEPHEN REISNER DENTISTRY SC
Entity type:Organization
Organization Name:DR STEPHEN REISNER DENTISTRY SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:D
Authorized Official - Last Name:REISNER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:715-532-5606
Mailing Address - Street 1:120 FIRST ST SO
Mailing Address - Street 2:
Mailing Address - City:LADYSMITH
Mailing Address - State:WI
Mailing Address - Zip Code:54848
Mailing Address - Country:US
Mailing Address - Phone:715-532-5606
Mailing Address - Fax:715-532-9675
Practice Address - Street 1:120 1ST ST S
Practice Address - Street 2:
Practice Address - City:LADYSMITH
Practice Address - State:WI
Practice Address - Zip Code:54848-1801
Practice Address - Country:US
Practice Address - Phone:715-532-5606
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-29
Last Update Date:2013-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI0003677122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33489100Medicaid