Provider Demographics
NPI:1962624643
Name:DIECK, GEORGE MICHAEL (DDS)
Entity type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:MICHAEL
Last Name:DIECK
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 1:609 W GREENWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:WAUKEGAN
Mailing Address - State:IL
Mailing Address - Zip Code:60087-5000
Mailing Address - Country:US
Mailing Address - Phone:847-244-9000
Mailing Address - Fax:847-244-0009
Practice Address - Street 1:609 W GREENWOOD AVE
Practice Address - Street 2:
Practice Address - City:WAUKEGAN
Practice Address - State:IL
Practice Address - Zip Code:60087-5000
Practice Address - Country:US
Practice Address - Phone:847-244-9000
Practice Address - Fax:847-244-0009
Is Sole Proprietor?:No
Enumeration Date:2007-05-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL19A124731223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice