Provider Demographics
NPI:1922107598
Name:DIETERLE, MARCIA LYNN (DDS)
Entity Type:Individual
Prefix:
First Name:MARCIA
Middle Name:LYNN
Last Name:DIETERLE
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 1:1035 FLORIDA AVENUE
Mailing Address - Street 2:
Mailing Address - City:KEYSER
Mailing Address - State:WV
Mailing Address - Zip Code:26726
Mailing Address - Country:US
Mailing Address - Phone:304-788-6647
Mailing Address - Fax:301-777-3624
Practice Address - Street 1:1035 FLORIDA AVENUE
Practice Address - Street 2:
Practice Address - City:KEYSER
Practice Address - State:WV
Practice Address - Zip Code:26726
Practice Address - Country:US
Practice Address - Phone:304-788-6647
Practice Address - Fax:301-777-3624
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV2833122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist