Healthcare Provider Details

I. General information

NPI: 1467563213
Provider Name (Legal Business Name): MICHAEL B. DIETRICH, D.M.D.,P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3439 BRIDGELAND DR
BRIDGETON MO
63044-2604
US

IV. Provider business mailing address

3439 BRIDGELAND DR
BRIDGETON MO
63044-2604
US

V. Phone/Fax

Practice location:
  • Phone: 314-291-2777
  • Fax: 314-291-9873
Mailing address:
  • Phone: 314-291-2777
  • Fax: 314-291-9873

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number14818
License Number StateMO

VIII. Authorized Official

Name: DR. MICHAEL BRIAN DIETRICH
Title or Position: PRESIDENT
Credential: D.M.D.
Phone: 314-291-2777