MEDICARE: DR. TRENTON PACE DITTMER M.D.

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	2085R0202X	Diagnostic Radiology Physician	39436	SC
2	390200000X	Student in an Organized Health Care Education/Training Program
3	2085R0202X	Diagnostic Radiology Physician	88225	GA

General Provider Information

NPI Number	:	1750639894
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. TRENTON PACE DITTMER M.D.

Provider Business Mailing Address
First Line	:	1365A CLIFTON RD NE STE AT-627
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30322-8905
Country	:	US
Telephone Number	:	404-778-4446
Fax Number	:

Provider Business Practice Location Address
First Line	:	1365A CLIFTON RD NE STE AT-627
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30322-8905
Country	:	US
Telephone Number	:	404-778-4446
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/21/2012
Last Update Date	:	05/04/2022

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