Provider Demographics
NPI:1316107709
Name:J MICHAEL DIERKES FAMILY ORTHODONTICS LLC
Entity type:Organization
Organization Name:J MICHAEL DIERKES FAMILY ORTHODONTICS LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRES
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:DIERKES
Authorized Official - Suffix:
Authorized Official - Credentials:DDS MS FICCMO NMD
Authorized Official - Phone:678-352-0919
Mailing Address - Street 1:910 MARIETTA HWY
Mailing Address - Street 2:SUITE
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30075-6771
Mailing Address - Country:US
Mailing Address - Phone:678-352-0919
Mailing Address - Fax:678-352-8330
Practice Address - Street 1:910 MARIETTA HWY
Practice Address - Street 2:SUITE
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30075-6771
Practice Address - Country:US
Practice Address - Phone:678-352-0919
Practice Address - Fax:678-352-8330
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-10
Last Update Date:2016-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA96751223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty