Provider Demographics
NPI:1487379277
Name:DIETRICH, DEXTER W (DC)
Entity type:Individual
Prefix:DR
First Name:DEXTER
Middle Name:W
Last Name:DIETRICH
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18931 E VALLEY VIEW PKWY STE C
Mailing Address - Street 2:
Mailing Address - City:INDEPENDENCE
Mailing Address - State:MO
Mailing Address - Zip Code:64055-7013
Mailing Address - Country:US
Mailing Address - Phone:816-350-0020
Mailing Address - Fax:
Practice Address - Street 1:18931 E VALLEY VIEW PKWY STE C
Practice Address - Street 2:
Practice Address - City:INDEPENDENCE
Practice Address - State:MO
Practice Address - Zip Code:64055-7013
Practice Address - Country:US
Practice Address - Phone:816-350-0020
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-05
Last Update Date:2022-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2022035879111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty