Provider Demographics
NPI:1619181419
Name:DIETRICH, CARL P III (DDS MSD)
Entity Type:Individual
Prefix:DR
First Name:CARL
Middle Name:P
Last Name:DIETRICH
Suffix:III
Gender:M
Credentials:DDS MSD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1690 W EXCHANGE ST
Mailing Address - Street 2:
Mailing Address - City:AKRON
Mailing Address - State:OH
Mailing Address - Zip Code:44313-7662
Mailing Address - Country:US
Mailing Address - Phone:330-864-2101
Mailing Address - Fax:330-864-3717
Practice Address - Street 1:1690 W EXCHANGE ST
Practice Address - Street 2:
Practice Address - City:AKRON
Practice Address - State:OH
Practice Address - Zip Code:44313-7662
Practice Address - Country:US
Practice Address - Phone:330-864-2101
Practice Address - Fax:330-864-3717
Is Sole Proprietor?:No
Enumeration Date:2007-05-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH192391223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics