Healthcare Provider Details

I. General information

NPI: 1518120047
Provider Name (Legal Business Name): CRAIG E DIETZ DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/03/2008
Last Update Date: 05/06/2020
Certification Date: 05/06/2020
Deactivation Date: 04/16/2020
Reactivation Date: 05/06/2020

III. Provider practice location address

48853 CALCUTTA SMITH FERRY RD
EAST LIVERPOOL OH
43920-9639
US

IV. Provider business mailing address

PO BOX 2742
EAST LIVERPOOL OH
43920-0742
US

V. Phone/Fax

Practice location:
  • Phone: 330-385-6216
  • Fax: 330-385-0716
Mailing address:
  • Phone: 330-385-6216
  • Fax: 330-385-0716

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number16890
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: