Provider Demographics
NPI:1902582604
Name:DIETRICH, JORDAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:JORDAN
Middle Name:
Last Name:DIETRICH
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4818 WOOD DUCK WAY
Mailing Address - Street 2:
Mailing Address - City:WEST BEND
Mailing Address - State:WI
Mailing Address - Zip Code:53095-9196
Mailing Address - Country:US
Mailing Address - Phone:920-639-9529
Mailing Address - Fax:
Practice Address - Street 1:825 W FULTON ST
Practice Address - Street 2:
Practice Address - City:WAUPACA
Practice Address - State:WI
Practice Address - Zip Code:54981-1471
Practice Address - Country:US
Practice Address - Phone:920-731-7445
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-26
Last Update Date:2023-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6001224-151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice