Provider Demographics
NPI:1548333792
Name:REISIG, SEAN A (DDS)
Entity type:Individual
Prefix:DR
First Name:SEAN
Middle Name:A
Last Name:REISIG
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 1:128 FRIENDSHIP AVE SE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97302-5716
Mailing Address - Country:US
Mailing Address - Phone:503-581-9552
Mailing Address - Fax:
Practice Address - Street 1:128 FRIENDSHIP AVE SE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97302-5716
Practice Address - Country:US
Practice Address - Phone:503-581-9552
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR74581223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice