MEDICARE: DR. KEVIN MICHAEL DIETTE M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207N00000X	Dermatology Physician	024290	CT

General Provider Information

NPI Number	:	1447252812
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KEVIN MICHAEL DIETTE M.D.

Provider Business Mailing Address
First Line	:	88 NOBLE AVE
Second Line	:
City	:	MILFORD
State	:	CT
Zip	:	06460-4738
Country	:	US
Telephone Number	:	203-878-3435
Fax Number	:	203-783-9689

Provider Business Practice Location Address
First Line	:	88 NOBLE AVE
Second Line	:
City	:	MILFORD
State	:	CT
Zip	:	06460-4738
Country	:	US
Telephone Number	:	203-878-3435
Fax Number	:	203-783-9689

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/15/2005
Last Update Date	:	10/04/2007

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