Provider Demographics
NPI:1982990578
Name:DIEDERICHS, JUSTIN ISAAC (DDS)
Entity Type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:ISAAC
Last Name:DIEDERICHS
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 1:635 MIKKELSEN DR
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:CA
Mailing Address - Zip Code:95603-3914
Mailing Address - Country:US
Mailing Address - Phone:530-885-5696
Mailing Address - Fax:530-885-5698
Practice Address - Street 1:635 MIKKELSEN DR
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:CA
Practice Address - Zip Code:95603-3914
Practice Address - Country:US
Practice Address - Phone:530-885-5696
Practice Address - Fax:530-885-5698
Is Sole Proprietor?:No
Enumeration Date:2011-06-22
Last Update Date:2016-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA604331223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice