Healthcare Provider Details

I. General information

NPI: 1053425504
Provider Name (Legal Business Name): THOMAS S DIETRICH D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/19/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1455 S SAWBURG RD
ALLIANCE OH
44601-3521
US

IV. Provider business mailing address

1455 S SAWBURG RD
ALLIANCE OH
44601-3521
US

V. Phone/Fax

Practice location:
  • Phone: 330-821-4187
  • Fax:
Mailing address:
  • Phone: 330-821-4187
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number30-01-5741
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: