Provider Demographics
NPI:1003185240
Name:DIETRICH DENTAL SERVICES PA
Entity Type:Organization
Organization Name:DIETRICH DENTAL SERVICES PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:LOUIS
Authorized Official - Last Name:DIETRICH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:941-625-7877
Mailing Address - Street 1:17178 TOLEDO BLADE BLVD
Mailing Address - Street 2:
Mailing Address - City:PORT CHARLOTTE
Mailing Address - State:FL
Mailing Address - Zip Code:33954-2626
Mailing Address - Country:US
Mailing Address - Phone:941-625-7877
Mailing Address - Fax:941-625-4349
Practice Address - Street 1:17178 TOLEDO BLADE BLVD
Practice Address - Street 2:
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33954-2626
Practice Address - Country:US
Practice Address - Phone:941-625-7877
Practice Address - Fax:941-625-4349
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-16
Last Update Date:2011-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN9422122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty