Provider Demographics
NPI:1053441667
Name:JAY L. NUTT & C. FRED PIETSCH, DDS, INC
Entity Type:Organization
Organization Name:JAY L. NUTT & C. FRED PIETSCH, DDS, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:C
Authorized Official - Middle Name:FRED
Authorized Official - Last Name:PIETSCH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:972-690-8617
Mailing Address - Street 1:1231 E BELT LINE RD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:RICHARDSON
Mailing Address - State:TX
Mailing Address - Zip Code:75081-3748
Mailing Address - Country:US
Mailing Address - Phone:972-690-8617
Mailing Address - Fax:972-690-6423
Practice Address - Street 1:1231 E BELT LINE RD
Practice Address - Street 2:SUITE 103
Practice Address - City:RICHARDSON
Practice Address - State:TX
Practice Address - Zip Code:75081-3748
Practice Address - Country:US
Practice Address - Phone:972-690-8617
Practice Address - Fax:972-690-6423
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX10340122300000X
TX10482122300000X
TX194731223P0300X
TX128071223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered122300000XDental ProvidersDentistGroup - Multi-Specialty
Not Answered1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty
Not Answered1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty