Provider Demographics
NPI:1326494022
Name:DITERLIZZI, JASON DERRICK (DDS)
Entity Type:Individual
Prefix:DR
First Name:JASON
Middle Name:DERRICK
Last Name:DITERLIZZI
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 1:5012 TALMADGE RD STE 100
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43623-2168
Mailing Address - Country:US
Mailing Address - Phone:419-474-9611
Mailing Address - Fax:
Practice Address - Street 1:5012 TALMADGE RD STE 100
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43623-2168
Practice Address - Country:US
Practice Address - Phone:419-474-9611
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-11
Last Update Date:2016-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30.24749122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist