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General NPI Number Information
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NPI Number | 1528153533
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Entity Type | Organization
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Legal Business Name | DIETRICH & ASSOCIATES ORAL AND MAXILLOFACIAL SURGERY, INC.
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Dates
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Enumeration Date | 10/04/2006
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Last Update Date | 01/24/2020
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Provider Practice Location Address
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Address Line | 4774 MUNSON ST NW SUITE 102
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City | CANTON
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State | OH
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Zip | 44718
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Country | US
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Telephone | 330-494-6653
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Fax | 330-494-6630
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Provider Business Mailing Address
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Address Line | 4774 MUNSON ST NW SUITE 102
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City | CANTON
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State | OH
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Zip | 44718
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Country | US
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Telephone | 330-494-6653
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Fax | 330-494-6630
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Authorized Official
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Title or Position | OWNER/PRESIDENT
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Name | THOMAS JOSEPH DIETRICH
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Credential | DDS, MD
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Telephone | 330-494-6653
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223S0112X
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Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
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License Number | 21924
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License Number State | OH
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