Provider Demographics
NPI:1720685027
Name:DIERKES, COURTNEY ANN (RDH)
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:ANN
Last Name:DIERKES
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1213B MONTANA PL
Mailing Address - Street 2:
Mailing Address - City:JOPLIN
Mailing Address - State:MO
Mailing Address - Zip Code:64804-2342
Mailing Address - Country:US
Mailing Address - Phone:314-899-7823
Mailing Address - Fax:
Practice Address - Street 1:530 S MAIDEN LN
Practice Address - Street 2:
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64801-3084
Practice Address - Country:US
Practice Address - Phone:417-782-6200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-08
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2018043179124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AMS202200OtherASPEN STM