Provider Demographics
NPI:1447860754
Name:REICHENBACH, MARIAH (DMD)
Entity type:Individual
Prefix:
First Name:MARIAH
Middle Name:
Last Name:REICHENBACH
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:MARIAH
Other - Middle Name:A
Other - Last Name:RICHARDS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DMD
Mailing Address - Street 1:PO BOX 205
Mailing Address - Street 2:
Mailing Address - City:SMITHVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:38870-0205
Mailing Address - Country:US
Mailing Address - Phone:662-651-7111
Mailing Address - Fax:662-651-7115
Practice Address - Street 1:60024 OLIVE ST
Practice Address - Street 2:
Practice Address - City:SMITHVILLE
Practice Address - State:MS
Practice Address - Zip Code:38870-9719
Practice Address - Country:US
Practice Address - Phone:662-651-7111
Practice Address - Fax:662-651-7115
Is Sole Proprietor?:No
Enumeration Date:2020-08-03
Last Update Date:2020-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS4151-201223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice