Healthcare Provider Details

I. General information

NPI: 1326494022
Provider Name (Legal Business Name): JASON DERRICK DITERLIZZI DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2016
Last Update Date: 05/11/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5012 TALMADGE RD STE 100
TOLEDO OH
43623-2168
US

IV. Provider business mailing address

5012 TALMADGE RD STE 100
TOLEDO OH
43623-2168
US

V. Phone/Fax

Practice location:
  • Phone: 419-474-9611
  • Fax:
Mailing address:
  • Phone: 419-474-9611
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number30.24749
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: