Provider Demographics
NPI:1467694505
Name:DIETRICH, JOSEPH (DMD)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:
Last Name:DIETRICH
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1455 S SAWBURG AVE
Mailing Address - Street 2:
Mailing Address - City:ALLIANCE
Mailing Address - State:OH
Mailing Address - Zip Code:44601-3521
Mailing Address - Country:US
Mailing Address - Phone:330-821-4187
Mailing Address - Fax:330-821-4641
Practice Address - Street 1:1455 S SAWBURG AVE
Practice Address - Street 2:
Practice Address - City:ALLIANCE
Practice Address - State:OH
Practice Address - Zip Code:44601-3521
Practice Address - Country:US
Practice Address - Phone:330-821-4187
Practice Address - Fax:330-821-4641
Is Sole Proprietor?:No
Enumeration Date:2009-04-06
Last Update Date:2014-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
OH30-0233211223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program