Provider Demographics
NPI:1740489038
Name:DIETRICH, MATTHEW A (DDS)
Entity type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:A
Last Name:DIETRICH
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11002 LONDON CIR
Mailing Address - Street 2:
Mailing Address - City:ARCADIA
Mailing Address - State:OK
Mailing Address - Zip Code:73007-1000
Mailing Address - Country:US
Mailing Address - Phone:319-331-8048
Mailing Address - Fax:
Practice Address - Street 1:3900 SUNFOREST CT
Practice Address - Street 2:SUITE 232
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43623-4475
Practice Address - Country:US
Practice Address - Phone:419-472-7668
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-16
Last Update Date:2015-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30.0234031223E0200X
IA085011223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics
No1223G0001XDental ProvidersDentistGeneral Practice