Provider Demographics
NPI:1558590851
Name:DIETZ, CRISTEN MARIE (DMD)
Entity Type:Individual
Prefix:DR
First Name:CRISTEN
Middle Name:MARIE
Last Name:DIETZ
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:DR
Other - First Name:CRISTEN
Other - Middle Name:MARIE
Other - Last Name:MENDOZA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DMD
Mailing Address - Street 1:1545 9TH ST SW
Mailing Address - Street 2:
Mailing Address - City:VERO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32962-4312
Mailing Address - Country:US
Mailing Address - Phone:772-257-8224
Mailing Address - Fax:772-213-3157
Practice Address - Street 1:12196 COUNTY ROAD 512
Practice Address - Street 2:
Practice Address - City:FELLSMERE
Practice Address - State:FL
Practice Address - Zip Code:32948-5463
Practice Address - Country:US
Practice Address - Phone:772-257-8224
Practice Address - Fax:772-213-3157
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-08
Last Update Date:2019-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN187801223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLDN18780OtherSTATE LICENSE