Provider Demographics
NPI:1528313087
Name:DIETZ, MANDY JO (DC)
Entity type:Individual
Prefix:DR
First Name:MANDY
Middle Name:JO
Last Name:DIETZ
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:418 E BROADWAY AVE
Mailing Address - Street 2:SUITE 222
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58501-4086
Mailing Address - Country:US
Mailing Address - Phone:701-223-8413
Mailing Address - Fax:701-425-0148
Practice Address - Street 1:418 E BROADWAY AVE
Practice Address - Street 2:SUITE 222
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58501-4086
Practice Address - Country:US
Practice Address - Phone:701-223-8413
Practice Address - Fax:701-425-0148
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-19
Last Update Date:2012-07-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
ND0911111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor