Provider Demographics
NPI:1053310458
Name:TIETZE, DENNIS D (MD)
Entity Type:Individual
Prefix:
First Name:DENNIS
Middle Name:D
Last Name:TIETZE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:DEPT CH 14389
Mailing Address - Street 2:
Mailing Address - City:PALATINE
Mailing Address - State:IL
Mailing Address - Zip Code:60055-4389
Mailing Address - Country:US
Mailing Address - Phone:785-295-8108
Mailing Address - Fax:785-231-5991
Practice Address - Street 1:1101 SW 29TH STREET
Practice Address - Street 2:
Practice Address - City:TOPEKA
Practice Address - State:KS
Practice Address - Zip Code:66611
Practice Address - Country:US
Practice Address - Phone:785-379-4600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-18
Last Update Date:2014-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS418256207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KSB69457Medicare UPIN
KS103087Medicare PIN