Provider Demographics
NPI:1073688610
Name:DITTERLINE, JOE DALE (DMD)
Entity Type:Individual
Prefix:
First Name:JOE
Middle Name:DALE
Last Name:DITTERLINE
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:667 E MINGUS AVE
Mailing Address - Street 2:
Mailing Address - City:COTTONWOOD
Mailing Address - State:AZ
Mailing Address - Zip Code:86326-3760
Mailing Address - Country:US
Mailing Address - Phone:928-634-7585
Mailing Address - Fax:928-634-7257
Practice Address - Street 1:667 E MINGUS AVE
Practice Address - Street 2:
Practice Address - City:COTTONWOOD
Practice Address - State:AZ
Practice Address - Zip Code:86326-3760
Practice Address - Country:US
Practice Address - Phone:928-634-7585
Practice Address - Fax:928-634-7257
Is Sole Proprietor?:No
Enumeration Date:2006-11-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD43951223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice