Provider Demographics
NPI:1437609260
Name:RIECK, NATHAN EDWARD (DMD)
Entity type:Individual
Prefix:
First Name:NATHAN
Middle Name:EDWARD
Last Name:RIECK
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 1:204 W PLUM ST
Mailing Address - Street 2:
Mailing Address - City:EDINBORO
Mailing Address - State:PA
Mailing Address - Zip Code:16412-6002
Mailing Address - Country:US
Mailing Address - Phone:814-734-4451
Mailing Address - Fax:
Practice Address - Street 1:7686 W RIDGE RD
Practice Address - Street 2:
Practice Address - City:FAIRVIEW
Practice Address - State:PA
Practice Address - Zip Code:16415-1074
Practice Address - Country:US
Practice Address - Phone:814-474-5022
Practice Address - Fax:814-474-5022
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-05
Last Update Date:2020-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS0413331223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1437609260Medicaid