Provider Demographics
NPI:1609002088
Name:DIETRICH, CHARLES (DDS)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:DIETRICH
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5028 WISCONSIN AVE NW
Mailing Address - Street 2:SUITE 102
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20016-4118
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5028 WISCONSIN AVE NW
Practice Address - Street 2:SUITE 102
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20016-4118
Practice Address - Country:US
Practice Address - Phone:202-363-6177
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-30
Last Update Date:2009-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCDEN 32881223G0001X
MD63991223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice