Basic Information
Provider Information | |||||||||
NPI: | 1154550382 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DIETZ | ||||||||
FirstName: | KRISTIAN | ||||||||
MiddleName: | CLYMER | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | DDS | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 4301 DONIPHAN DR | ||||||||
Address2: |   | ||||||||
City: | NEOSHO | ||||||||
State: | MO | ||||||||
PostalCode: | 648509120 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4174519450 | ||||||||
FaxNumber: | 4174518903 | ||||||||
Practice Location | |||||||||
Address1: | 530 S MAIDEN LN | ||||||||
Address2: |   | ||||||||
City: | JOPLIN | ||||||||
State: | MO | ||||||||
PostalCode: | 648013084 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4177820080 | ||||||||
FaxNumber: | 4177820096 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/09/2009 | ||||||||
LastUpdateDate: | 03/06/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 2009014596 | MO | Y |   | Dental Providers | Dentist |   |
No ID Information.