Basic Information
| Provider Information | |||||||||
| NPI: | 1558748434 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | REISS | ||||||||
| FirstName: | STACEY | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | DDS, MDENTSC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5110 EAKES RD NW | ||||||||
| Address2: | |||||||||
| City: | LOS RANCHOS | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871075538 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2032471456 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2800 COORS BLVD NW STE A | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871201204 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5053521166 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/30/2015 | ||||||||
| LastUpdateDate: | 04/17/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/17/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223X0400X | DD4909 | NM | Y | Dental Providers | Dentist | Orthodontics and Dentofacial Orthopedics |
No ID Information.