Provider Demographics
NPI:1548497043
Name:REITZ, THOMAS H (DDS, SC)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:H
Last Name:REITZ
Suffix:
Gender:M
Credentials:DDS, SC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1007 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:EDGERTON
Mailing Address - State:WI
Mailing Address - Zip Code:53534-1325
Mailing Address - Country:US
Mailing Address - Phone:608-884-3358
Mailing Address - Fax:608-884-4917
Practice Address - Street 1:1007 N MAIN ST
Practice Address - Street 2:
Practice Address - City:EDGERTON
Practice Address - State:WI
Practice Address - Zip Code:53534-1325
Practice Address - Country:US
Practice Address - Phone:608-884-3358
Practice Address - Fax:608-884-4917
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-11
Last Update Date:2009-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI39531223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice