Healthcare Provider Details

I. General information

NPI: 1053310458
Provider Name (Legal Business Name): DENNIS D TIETZE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2005
Last Update Date: 01/08/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 SW 29TH STREET
TOPEKA KS
66611
US

IV. Provider business mailing address

DEPT CH 14389
PALATINE IL
60055-4389
US

V. Phone/Fax

Practice location:
  • Phone: 785-379-4600
  • Fax:
Mailing address:
  • Phone: 785-295-8108
  • Fax: 785-231-5991

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number418256
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: