Provider Demographics
NPI:1689819260
Name:DIETRICH DENTAL P.S.C
Entity Type:Organization
Organization Name:DIETRICH DENTAL P.S.C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:RENE
Authorized Official - Middle Name:
Authorized Official - Last Name:DIETRICH-TRIGO
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:787-705-5063
Mailing Address - Street 1:LA GALERIA SUCHVILLE 97
Mailing Address - Street 2:CARR. 2 SUITE 208
Mailing Address - City:GUAYNABO
Mailing Address - State:PR
Mailing Address - Zip Code:00966
Mailing Address - Country:US
Mailing Address - Phone:787-705-5063
Mailing Address - Fax:787-705-5065
Practice Address - Street 1:LA GALERIA SUCHVILLE 97 CARR 2
Practice Address - Street 2:STE 208
Practice Address - City:GUAYNABO
Practice Address - State:PR
Practice Address - Zip Code:00966
Practice Address - Country:US
Practice Address - Phone:787-705-5063
Practice Address - Fax:787-705-5065
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-10
Last Update Date:2008-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR2179302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization