Provider Demographics
NPI:1477874899
Name:TIETJEN, RACHEL J (DDS)
Entity type:Individual
Prefix:DR
First Name:RACHEL
Middle Name:J
Last Name:TIETJEN
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 1:3220 PLAZA DR
Mailing Address - Street 2:
Mailing Address - City:SOUTH SIOUX CITY
Mailing Address - State:NE
Mailing Address - Zip Code:68776-3160
Mailing Address - Country:US
Mailing Address - Phone:402-494-2144
Mailing Address - Fax:
Practice Address - Street 1:3220 PLAZA DR
Practice Address - Street 2:
Practice Address - City:SOUTH SIOUX CITY
Practice Address - State:NE
Practice Address - Zip Code:68776-3160
Practice Address - Country:US
Practice Address - Phone:402-494-2144
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-21
Last Update Date:2015-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE6885122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist