Provider Demographics
NPI:1245362409
Name:DIETTERICK, BRUCE (DDS, MS, PC)
Entity type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:
Last Name:DIETTERICK
Suffix:
Gender:M
Credentials:DDS, MS, PC
Other - Prefix:DR
Other - First Name:BRUCE
Other - Middle Name:
Other - Last Name:DIETTERICK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS, MS, PC
Mailing Address - Street 1:1589 CARLISLE ROAD
Mailing Address - Street 2:
Mailing Address - City:YORK
Mailing Address - State:PA
Mailing Address - Zip Code:17408
Mailing Address - Country:US
Mailing Address - Phone:717-764-3854
Mailing Address - Fax:717-764-5855
Practice Address - Street 1:1589 CARLISLE ROAD
Practice Address - Street 2:
Practice Address - City:YORK
Practice Address - State:PA
Practice Address - Zip Code:17408
Practice Address - Country:US
Practice Address - Phone:717-764-3854
Practice Address - Fax:717-764-5855
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA0194191223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics