Provider Demographics
NPI:1033811922
Name:DEIDRICK, KAITLIN RENEE
Entity type:Individual
Prefix:
First Name:KAITLIN
Middle Name:RENEE
Last Name:DEIDRICK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4100 S HOSPITAL DR STE 205
Mailing Address - Street 2:
Mailing Address - City:PLANTATION
Mailing Address - State:FL
Mailing Address - Zip Code:33317-2837
Mailing Address - Country:US
Mailing Address - Phone:954-731-7030
Mailing Address - Fax:
Practice Address - Street 1:4100 S HOSPITAL DR STE 205
Practice Address - Street 2:
Practice Address - City:PLANTATION
Practice Address - State:FL
Practice Address - Zip Code:33317-2837
Practice Address - Country:US
Practice Address - Phone:954-731-7030
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-21
Last Update Date:2024-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN294701223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice