Provider Demographics
NPI:1780899674
Name:DIETRICH, JOHN LOUIS (DDS)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:LOUIS
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 1:17178 TOLEDO BLADE BLVD
Mailing Address - Street 2:
Mailing Address - City:PORT CHARLOTTE
Mailing Address - State:FL
Mailing Address - Zip Code:33954-2626
Mailing Address - Country:US
Mailing Address - Phone:941-625-7877
Mailing Address - Fax:941-625-4349
Practice Address - Street 1:17178 TOLEDO BLADE BLVD
Practice Address - Street 2:
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33954-2626
Practice Address - Country:US
Practice Address - Phone:941-625-7877
Practice Address - Fax:941-625-4349
Is Sole Proprietor?:No
Enumeration Date:2007-05-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN94221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice