Provider Demographics
NPI:1922018381
Name:DIETZ, JOHN B (DMD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:B
Last Name:DIETZ
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 1:2210 WILMINTON RD
Mailing Address - Street 2:
Mailing Address - City:NEW CASTLE
Mailing Address - State:PA
Mailing Address - Zip Code:16105-1997
Mailing Address - Country:US
Mailing Address - Phone:724-652-7491
Mailing Address - Fax:724-652-0810
Practice Address - Street 1:2210 WILMINTON RD
Practice Address - Street 2:
Practice Address - City:NEW CASTLE
Practice Address - State:PA
Practice Address - Zip Code:16105-1997
Practice Address - Country:US
Practice Address - Phone:724-652-7491
Practice Address - Fax:724-652-0810
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2014-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS021716122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1016280930001Medicaid