Provider Demographics
NPI:1699192948
Name:DIETZLER, ELIZABETH S (RDH)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:S
Last Name:DIETZLER
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4619 W BLUE MOUND CT
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53208-3607
Mailing Address - Country:US
Mailing Address - Phone:414-339-5523
Mailing Address - Fax:
Practice Address - Street 1:4619 W BLUE MOUND CT
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53208-3607
Practice Address - Country:US
Practice Address - Phone:414-339-5523
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-25
Last Update Date:2014-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI10453-016124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist