Healthcare Provider Details

I. General information

NPI: 1841301942
Provider Name (Legal Business Name): THOMAS J DIETRICH DDS, MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 08/31/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4774 MUNSON ST NW SUITE 102
CANTON OH
44718-3634
US

IV. Provider business mailing address

4774 MUNSON ST NW SUITE 102
CANTON OH
44718-3634
US

V. Phone/Fax

Practice location:
  • Phone: 330-494-6653
  • Fax: 330-494-6630
Mailing address:
  • Phone: 330-494-6653
  • Fax: 330-494-6630

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number21924
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code1223P0106X
TaxonomyOral and Maxillofacial Pathology Dentistry
License Number21924
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: