Provider Demographics
NPI:1215020938
Name:RICHARD D. DIETZ, DDS INC.
Entity Type:Organization
Organization Name:RICHARD D. DIETZ, DDS INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:DIETZ,
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:937-653-5359
Mailing Address - Street 1:314 PATRICK AVENUE
Mailing Address - Street 2:
Mailing Address - City:URBANA
Mailing Address - State:OH
Mailing Address - Zip Code:43078
Mailing Address - Country:US
Mailing Address - Phone:937-653-5359
Mailing Address - Fax:937-653-5964
Practice Address - Street 1:314 PATRICK AVENUE
Practice Address - Street 2:
Practice Address - City:URBANA
Practice Address - State:OH
Practice Address - Zip Code:43078
Practice Address - Country:US
Practice Address - Phone:937-653-5359
Practice Address - Fax:937-653-5964
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-02
Last Update Date:2008-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30-015069122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0321226Medicaid