Provider Demographics
NPI:1841301942
Name:DIETRICH, THOMAS J (DDS, MD)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:J
Last Name:DIETRICH
Suffix:
Gender:M
Credentials:DDS, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4774 MUNSON ST NW
Mailing Address - Street 2:SUITE 102
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44718-3634
Mailing Address - Country:US
Mailing Address - Phone:330-494-6653
Mailing Address - Fax:330-494-6630
Practice Address - Street 1:4774 MUNSON ST NW
Practice Address - Street 2:SUITE 102
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44718-3634
Practice Address - Country:US
Practice Address - Phone:330-494-6653
Practice Address - Fax:330-494-6630
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2010-08-31
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OH219241223S0112X, 1223P0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No1223P0106XDental ProvidersDentistOral and Maxillofacial Pathology