Provider Demographics
NPI:1164586269
Name:GUERRETTAZ, DEIDRE EAST (DDS)
Entity Type:Individual
Prefix:MRS
First Name:DEIDRE
Middle Name:EAST
Last Name:GUERRETTAZ
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4809 N PENNSYLVANIA ST
Mailing Address - Street 2:
Mailing Address - City:INDPLS
Mailing Address - State:IN
Mailing Address - Zip Code:46205
Mailing Address - Country:US
Mailing Address - Phone:317-283-5225
Mailing Address - Fax:
Practice Address - Street 1:4809 N PENNSYLVANIA ST
Practice Address - Street 2:
Practice Address - City:INDPLS
Practice Address - State:IN
Practice Address - Zip Code:46205
Practice Address - Country:US
Practice Address - Phone:317-283-5225
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-21
Last Update Date:2013-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN120087491223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100120810AMedicaid