Provider Demographics
NPI:1326022872
Name:DIETZ, MICHAEL WAYNE (DDS)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:WAYNE
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 1:3397 MIDDLEFORD DR
Mailing Address - Street 2:
Mailing Address - City:COOKEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38506-6120
Mailing Address - Country:US
Mailing Address - Phone:931-372-1647
Mailing Address - Fax:931-537-2215
Practice Address - Street 1:3397 MIDDLEFORD DR
Practice Address - Street 2:
Practice Address - City:COOKEVILLE
Practice Address - State:TN
Practice Address - Zip Code:38506-6120
Practice Address - Country:US
Practice Address - Phone:931-372-1647
Practice Address - Fax:931-537-2215
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-30
Last Update Date:2021-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDS28391223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT2383OtherDENTAL LICENSE
TNDS2839OtherDENTAL LICENSE