Provider Demographics
NPI:1598549107
Name:DIETZ, NICHOLAS
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:
Last Name:DIETZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4329 LOMA RIVIERA CT
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92110-5504
Mailing Address - Country:US
Mailing Address - Phone:541-390-3966
Mailing Address - Fax:
Practice Address - Street 1:3737 MURPHY CANYON RD
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-4454
Practice Address - Country:US
Practice Address - Phone:858-694-0790
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-23
Last Update Date:2023-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA109191122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist