Provider Demographics
NPI:1053425504
Name:DIETRICH, THOMAS S (DDS)
Entity type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:S
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 1:1455 S SAWBURG RD
Mailing Address - Street 2:
Mailing Address - City:ALLIANCE
Mailing Address - State:OH
Mailing Address - Zip Code:44601-3521
Mailing Address - Country:US
Mailing Address - Phone:330-821-4187
Mailing Address - Fax:
Practice Address - Street 1:1455 S SAWBURG RD
Practice Address - Street 2:
Practice Address - City:ALLIANCE
Practice Address - State:OH
Practice Address - Zip Code:44601-3521
Practice Address - Country:US
Practice Address - Phone:330-821-4187
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30-01-57411223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics