Provider Demographics
NPI:1710116934
Name:DIETZ, KAITLIN CRONAN (DDS)
Entity Type:Individual
Prefix:
First Name:KAITLIN
Middle Name:CRONAN
Last Name:DIETZ
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1603 SW REGIONAL AIRPORT BLVD
Mailing Address - Street 2:
Mailing Address - City:BENTONVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72712-7359
Mailing Address - Country:US
Mailing Address - Phone:479-715-9428
Mailing Address - Fax:
Practice Address - Street 1:530 S MAIDEN LN
Practice Address - Street 2:
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64801-3084
Practice Address - Country:US
Practice Address - Phone:417-782-0080
Practice Address - Fax:417-782-0096
Is Sole Proprietor?:No
Enumeration Date:2009-07-09
Last Update Date:2015-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR39811223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice