Provider Demographics
NPI:1598543563
Name:NV DIETRICH DENTISTRY PC
Entity Type:Organization
Organization Name:NV DIETRICH DENTISTRY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:JACOMINO-BARNES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:800-277-3633
Mailing Address - Street 1:PO BOX 70887
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44190-0887
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4099 RIVERDALE RD STE A
Practice Address - Street 2:
Practice Address - City:RIVERDALE
Practice Address - State:UT
Practice Address - Zip Code:84405-1569
Practice Address - Country:US
Practice Address - Phone:385-405-7044
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-09-20
Last Update Date:2024-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty