Provider Demographics
NPI:1528127024
Name:THIEDE, CRAIG CARL (DDS)
Entity type:Individual
Prefix:
First Name:CRAIG
Middle Name:CARL
Last Name:THIEDE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13522 NEWPORT AVE STE 109
Mailing Address - Street 2:
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92780-3707
Mailing Address - Country:US
Mailing Address - Phone:714-730-6767
Mailing Address - Fax:714-730-1161
Practice Address - Street 1:13522 NEWPORT AVE STE 109
Practice Address - Street 2:
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780-3707
Practice Address - Country:US
Practice Address - Phone:714-730-6767
Practice Address - Fax:714-730-1161
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-08
Last Update Date:2022-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA408921223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAB40892-01Medicaid
CA46633Medicare UPIN