Provider Demographics
NPI:1497795660
Name:DIETZ, GERALD C JR (DDS)
Entity Type:Individual
Prefix:DR
First Name:GERALD
Middle Name:C
Last Name:DIETZ
Suffix:JR
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:50 W BIG BEAVER RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:BLOOMFIELD HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48304-3910
Mailing Address - Country:US
Mailing Address - Phone:248-647-7930
Mailing Address - Fax:248-647-0576
Practice Address - Street 1:50 W BIG BEAVER RD
Practice Address - Street 2:SUITE 200
Practice Address - City:BLOOMFIELD HILLS
Practice Address - State:MI
Practice Address - Zip Code:48304-3910
Practice Address - Country:US
Practice Address - Phone:248-647-7930
Practice Address - Fax:248-647-0576
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI137331223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics