Provider Demographics
NPI:1144733130
Name:DIEKMANN, LYDIA J (ADT)
Entity type:Individual
Prefix:
First Name:LYDIA
Middle Name:J
Last Name:DIEKMANN
Suffix:
Gender:F
Credentials:ADT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2711 BROADWAY AVE STE A00
Mailing Address - Street 2:
Mailing Address - City:SLAYTON
Mailing Address - State:MN
Mailing Address - Zip Code:56172-1313
Mailing Address - Country:US
Mailing Address - Phone:507-836-1000
Mailing Address - Fax:507-836-1008
Practice Address - Street 1:2711 BROADWAY AVE STE A00
Practice Address - Street 2:
Practice Address - City:SLAYTON
Practice Address - State:MN
Practice Address - Zip Code:56172-1313
Practice Address - Country:US
Practice Address - Phone:507-836-1000
Practice Address - Fax:507-836-1008
Is Sole Proprietor?:No
Enumeration Date:2017-11-13
Last Update Date:2017-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNDT37125K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes125K00000XDental ProvidersAdvanced Practice Dental Therapist