Provider Demographics
NPI:1821327198
Name:DIETZ, MEGAN ELIZABETH (DDS)
Entity Type:Individual
Prefix:DR
First Name:MEGAN
Middle Name:ELIZABETH
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 1:1 CIVIC CENTER DR
Mailing Address - Street 2:SAN MARCOS CIVIC CENTER, SUITE 110
Mailing Address - City:SAN MARCOS
Mailing Address - State:CA
Mailing Address - Zip Code:92069-2918
Mailing Address - Country:US
Mailing Address - Phone:760-752-1430
Mailing Address - Fax:760-752-1598
Practice Address - Street 1:1 CIVIC CENTER DR
Practice Address - Street 2:SAN MARCOS CIVIC CENTER, SUITE 110
Practice Address - City:SAN MARCOS
Practice Address - State:CA
Practice Address - Zip Code:92069-2918
Practice Address - Country:US
Practice Address - Phone:760-752-1430
Practice Address - Fax:760-752-1598
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-16
Last Update Date:2009-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA58917122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist