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General NPI Number Information
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NPI Number | 1952723215
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Entity Type | Organization
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Legal Business Name | KRISTIAN C. DIETZ, DDS, PLLC
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Dates
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Enumeration Date | 01/06/2014
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Last Update Date | 01/06/2014
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Provider Practice Location Address
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Address Line | 1603 SW REGIONAL AIRPORT BLVD.
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City | BENTONVILLE
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State | AR
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Zip | 72712
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Country | US
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Telephone | 479-715-4277
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Fax |
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Provider Business Mailing Address
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Address Line | 1603 SW REGIONAL AIRPORT BLVD.
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City | BENTONVILLE
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State | AR
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Zip | 72712
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Country | US
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Telephone | 479-715-4277
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Fax |
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Authorized Official
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Title or Position | OWNER DENTIST
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Name | DR. KRISTIAN C DIETZ
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Credential | DDS
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Telephone | 479-715-4277
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 3913
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License Number State | AR
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