Provider Demographics
NPI:1750304523
Name:DIETRICH, THOMAS ALEX (DDS)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:ALEX
Last Name:DIETRICH
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 1:400 JEFFERSON AVE
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:PA
Mailing Address - Zip Code:15301-4261
Mailing Address - Country:US
Mailing Address - Phone:724-228-4880
Mailing Address - Fax:724-228-8829
Practice Address - Street 1:400 JEFFERSON AVE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:PA
Practice Address - Zip Code:15301-4261
Practice Address - Country:US
Practice Address - Phone:724-228-4880
Practice Address - Fax:724-228-8829
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS-022233-L1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice