Provider Demographics
NPI:1992859920
Name:DIETRICH, RICHARD L (DMD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:L
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 1:2250 NW FLANDERS ST
Mailing Address - Street 2:SUITE 109
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97210-3443
Mailing Address - Country:US
Mailing Address - Phone:503-228-6294
Mailing Address - Fax:503-228-6295
Practice Address - Street 1:2250 NW FLANDERS ST
Practice Address - Street 2:SUITE 109
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97210-3443
Practice Address - Country:US
Practice Address - Phone:503-228-6294
Practice Address - Fax:503-228-6295
Is Sole Proprietor?:No
Enumeration Date:2007-01-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD68841223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice