Provider Demographics
NPI:1467874941
Name:DIETZE, JOSHUA ALAN (DC)
Entity Type:Individual
Prefix:DR
First Name:JOSHUA
Middle Name:ALAN
Last Name:DIETZE
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 281
Mailing Address - Street 2:
Mailing Address - City:PEQUOT LAKES
Mailing Address - State:MN
Mailing Address - Zip Code:56472-0281
Mailing Address - Country:US
Mailing Address - Phone:218-568-7767
Mailing Address - Fax:
Practice Address - Street 1:31095 BERQUIST DR
Practice Address - Street 2:
Practice Address - City:PEQUOT LAKES
Practice Address - State:MN
Practice Address - Zip Code:56472-5647
Practice Address - Country:US
Practice Address - Phone:218-568-7767
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-17
Last Update Date:2021-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4951-12111N00000X
MN6714111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor