Provider Demographics
NPI:1669648721
Name:BRETT B. DIETERLEN D.D.S., P.C.
Entity Type:Organization
Organization Name:BRETT B. DIETERLEN D.D.S., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:BRETT
Authorized Official - Middle Name:B
Authorized Official - Last Name:DIETERLEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS,PC
Authorized Official - Phone:918-299-2400
Mailing Address - Street 1:3015 E 91ST ST
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74137-3324
Mailing Address - Country:US
Mailing Address - Phone:918-299-2400
Mailing Address - Fax:
Practice Address - Street 1:3015 E 91ST ST
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74137-3324
Practice Address - Country:US
Practice Address - Phone:918-299-2400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-07
Last Update Date:2008-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK5167305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization