Provider Demographics
NPI:1316261449
Name:DIETZ, MATTHEW KONRAD (DMD,MS)
Entity type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:KONRAD
Last Name:DIETZ
Suffix:
Gender:M
Credentials:DMD,MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3251 COMMERCE DR STE A
Mailing Address - Street 2:
Mailing Address - City:DEKALB
Mailing Address - State:IL
Mailing Address - Zip Code:60115-7908
Mailing Address - Country:US
Mailing Address - Phone:815-756-8881
Mailing Address - Fax:815-756-8882
Practice Address - Street 1:3251 COMMERCE DR STE A
Practice Address - Street 2:
Practice Address - City:DEKALB
Practice Address - State:IL
Practice Address - Zip Code:60115-7908
Practice Address - Country:US
Practice Address - Phone:815-756-8881
Practice Address - Fax:815-756-8882
Is Sole Proprietor?:No
Enumeration Date:2010-03-18
Last Update Date:2010-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0210016681223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics