Provider Demographics
NPI:1881872398
Name:ROD K DIETZ DDS PA
Entity type:Organization
Organization Name:ROD K DIETZ DDS PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROD
Authorized Official - Middle Name:K
Authorized Official - Last Name:DIETZ
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:727-512-6796
Mailing Address - Street 1:624 E TARPON AVE
Mailing Address - Street 2:
Mailing Address - City:TARPON SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:34689
Mailing Address - Country:US
Mailing Address - Phone:727-944-3777
Mailing Address - Fax:727-942-7407
Practice Address - Street 1:624 E TARPON AVE
Practice Address - Street 2:
Practice Address - City:TARPON SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:34689
Practice Address - Country:US
Practice Address - Phone:727-944-3777
Practice Address - Fax:727-942-7407
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-06
Last Update Date:2008-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN 151321223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty