Provider Demographics
NPI:1750492500
Name:DIETRICH, MICHAEL BRIAN (DMD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:BRIAN
Last Name:DIETRICH
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3439 BRIDGELAND DR
Mailing Address - Street 2:
Mailing Address - City:BRIDGETON
Mailing Address - State:MO
Mailing Address - Zip Code:63044-2604
Mailing Address - Country:US
Mailing Address - Phone:314-291-2777
Mailing Address - Fax:314-291-9873
Practice Address - Street 1:3439 BRIDGELAND DR
Practice Address - Street 2:
Practice Address - City:BRIDGETON
Practice Address - State:MO
Practice Address - Zip Code:63044-2604
Practice Address - Country:US
Practice Address - Phone:314-291-2777
Practice Address - Fax:314-291-9873
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO14818122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist