MEDICARE: RSS MICHAEL DIERKES LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	DN009675	GA

General Provider Information

NPI Number	:	1720595994
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RSS MICHAEL DIERKES LLC

Provider Business Mailing Address
First Line	:	1050 TEXAN TRL STE 300
Second Line	:
City	:	GRAPEVINE
State	:	TX
Zip	:	76051-3759
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4920 ROSWELL RD STE 255
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30342-2686
Country	:	US
Telephone Number	:	844-859-2525
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MICHAEL DIERKES
Credential	:
Telephone Number	:	817-405-7470

Provider Enumeration Date	:	01/09/2018
Last Update Date	:	01/27/2019

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