Provider Demographics
NPI:1568517597
Name:JOE D. DITTERLINE, D.M.D., P.C.
Entity Type:Organization
Organization Name:JOE D. DITTERLINE, D.M.D., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOE
Authorized Official - Middle Name:DALE
Authorized Official - Last Name:DITTERLINE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:928-634-7585
Mailing Address - Street 1:667 E MINGUS AVE
Mailing Address - Street 2:
Mailing Address - City:COTTONWOOD
Mailing Address - State:AZ
Mailing Address - Zip Code:86326-3760
Mailing Address - Country:US
Mailing Address - Phone:928-634-7585
Mailing Address - Fax:928-634-7257
Practice Address - Street 1:667 E MINGUS AVE
Practice Address - Street 2:
Practice Address - City:COTTONWOOD
Practice Address - State:AZ
Practice Address - Zip Code:86326-3760
Practice Address - Country:US
Practice Address - Phone:928-634-7585
Practice Address - Fax:928-634-7257
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD43951223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty