Provider Demographics
NPI:1831358795
Name:DIERKES, JOHN MICHAEL (DDS MS FICCMO)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:MICHAEL
Last Name:DIERKES
Suffix:
Gender:M
Credentials:DDS MS FICCMO
Other - Prefix:
Other - First Name:J
Other - Middle Name:MICHAEL
Other - Last Name:DIERKES
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS MS
Mailing Address - Street 1:603 W CROSSVILLE ROAD
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30075
Mailing Address - Country:US
Mailing Address - Phone:678-352-0919
Mailing Address - Fax:
Practice Address - Street 1:603 W CROSSVILLE RD
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30075-2507
Practice Address - Country:US
Practice Address - Phone:678-352-0919
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-05
Last Update Date:2015-09-18
Deactivation Date:2008-08-12
Deactivation Code:
Reactivation Date:2015-09-18
Provider Licenses
StateLicense IDTaxonomies
GA96751223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics