Provider Demographics
NPI:1871677245
Name:DIETRICH, DENNIS W (MD)
Entity Type:Individual
Prefix:
First Name:DENNIS
Middle Name:W
Last Name:DIETRICH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 15TH AVE S
Mailing Address - Street 2:STE 206
Mailing Address - City:GREAT FALLS
Mailing Address - State:MT
Mailing Address - Zip Code:59405-4375
Mailing Address - Country:US
Mailing Address - Phone:406-727-3720
Mailing Address - Fax:406-727-0007
Practice Address - Street 1:400 15TH AVE S
Practice Address - Street 2:STE 206
Practice Address - City:GREAT FALLS
Practice Address - State:MT
Practice Address - Zip Code:59405-4375
Practice Address - Country:US
Practice Address - Phone:406-727-3720
Practice Address - Fax:406-727-0007
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT52232084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT075036Medicaid
MTD07958Medicare UPIN
MT001939Medicare ID - Type Unspecified