Provider Demographics
NPI:1073643417
Name:DIETZ, CLAY CUNNINGHAM (DDS)
Entity Type:Individual
Prefix:DR
First Name:CLAY
Middle Name:CUNNINGHAM
Last Name:DIETZ
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 1:3733 RAVENA AVE
Mailing Address - Street 2:
Mailing Address - City:ROYAL OAK
Mailing Address - State:MI
Mailing Address - Zip Code:48073-6439
Mailing Address - Country:US
Mailing Address - Phone:734-320-9993
Mailing Address - Fax:
Practice Address - Street 1:5877 LIVERNOIS RD
Practice Address - Street 2:SUITE #106
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48098-3100
Practice Address - Country:US
Practice Address - Phone:248-828-3636
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010186931223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics