Provider Demographics
NPI:1467643098
Name:DIETRICH, CAROLYN MASSA (DMD)
Entity Type:Individual
Prefix:DR
First Name:CAROLYN
Middle Name:MASSA
Last Name:DIETRICH
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:39 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:BEVERLY
Mailing Address - State:MA
Mailing Address - Zip Code:01915-4417
Mailing Address - Country:US
Mailing Address - Phone:978-927-5247
Mailing Address - Fax:978-922-7369
Practice Address - Street 1:39 BROADWAY
Practice Address - Street 2:
Practice Address - City:BEVERLY
Practice Address - State:MA
Practice Address - Zip Code:01915-4417
Practice Address - Country:US
Practice Address - Phone:978-927-5247
Practice Address - Fax:978-922-7369
Is Sole Proprietor?:No
Enumeration Date:2007-08-08
Last Update Date:2015-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA21970122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist