Provider Demographics
NPI:1144765793
Name:DANIEL M DIETRICH, DDS, PC
Entity Type:Organization
Organization Name:DANIEL M DIETRICH, DDS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS ASSISTANT
Authorized Official - Prefix:
Authorized Official - First Name:WENDY
Authorized Official - Middle Name:
Authorized Official - Last Name:THOMPSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-246-7900
Mailing Address - Street 1:1105 W STONE DR
Mailing Address - Street 2:
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37660-2558
Mailing Address - Country:US
Mailing Address - Phone:423-246-7900
Mailing Address - Fax:423-246-1503
Practice Address - Street 1:1105 W STONE DR
Practice Address - Street 2:
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660-2558
Practice Address - Country:US
Practice Address - Phone:423-246-7900
Practice Address - Fax:423-246-1503
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-05
Last Update Date:2017-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN30411223G0001X
TN52851223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty