Provider Demographics
NPI:1871535963
Name:DIETL, ERNEST L JR
Entity type:Individual
Prefix:DR
First Name:ERNEST
Middle Name:L
Last Name:DIETL
Suffix:JR
Gender:M
Credentials:
Other - Prefix:DR
Other - First Name:ERNEST
Other - Middle Name:L
Other - Last Name:DIETL
Other - Suffix:JR
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:5 CENTRE ST
Mailing Address - Street 2:SUITE 1
Mailing Address - City:PARK FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60466-2001
Mailing Address - Country:US
Mailing Address - Phone:708-748-2800
Mailing Address - Fax:
Practice Address - Street 1:5 CENTRE ST
Practice Address - Street 2:SUITE 1
Practice Address - City:PARK FOREST
Practice Address - State:IL
Practice Address - Zip Code:60466-2001
Practice Address - Country:US
Practice Address - Phone:708-748-2800
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist