Provider Demographics
NPI:1598725715
Name:DIETRICH, JUSTIN D (DC)
Entity Type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:D
Last Name:DIETRICH
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:404 N HAMPTON CT
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:DE
Mailing Address - Zip Code:19709-7944
Mailing Address - Country:US
Mailing Address - Phone:302-376-8868
Mailing Address - Fax:
Practice Address - Street 1:2600 GLASGOW AVE
Practice Address - Street 2:SUITE 120
Practice Address - City:NEWARK
Practice Address - State:DE
Practice Address - Zip Code:19702-4777
Practice Address - Country:US
Practice Address - Phone:302-836-8200
Practice Address - Fax:302-836-5173
Is Sole Proprietor?:No
Enumeration Date:2006-03-23
Last Update Date:2011-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEF10000583111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor