Provider Demographics
NPI:1679743082
Name:THIETTEN, JEREMEY J (DDS)
Entity Type:Individual
Prefix:DR
First Name:JEREMEY
Middle Name:J
Last Name:THIETTEN
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 1:924 S LINCOLN AVE
Mailing Address - Street 2:PO BOX 530
Mailing Address - City:LAKEVIEW
Mailing Address - State:MI
Mailing Address - Zip Code:48850-9174
Mailing Address - Country:US
Mailing Address - Phone:989-352-6477
Mailing Address - Fax:989-352-8348
Practice Address - Street 1:924 S LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:LAKEVIEW
Practice Address - State:MI
Practice Address - Zip Code:48850-9174
Practice Address - Country:US
Practice Address - Phone:989-352-6477
Practice Address - Fax:989-352-8348
Is Sole Proprietor?:No
Enumeration Date:2008-03-03
Last Update Date:2009-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5315032828122300000X
MI2901019669122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist