MEDICARE: GRISEL GONZALEZ-DIAZ INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	G93596-01	OTHER	CA	DENTI-CAL

General Provider Information

NPI Number	:	1063609196
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GRISEL GONZALEZ-DIAZ INC

Provider Business Mailing Address
First Line	:	7201 ARLINGTON AVE STE A
Second Line	:
City	:	RIVERSIDE
State	:	CA
Zip	:	92503-1518
Country	:	US
Telephone Number	:	951-785-4200
Fax Number	:

Provider Business Practice Location Address
First Line	:	7201 ARLINGTON AVE STE A
Second Line	:
City	:	RIVERSIDE
State	:	CA
Zip	:	92503-1518
Country	:	US
Telephone Number	:	951-785-4200
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT OF CORPORATION
Name	:	MRS. GRISEL GONZALEZ-DIAZ
Credential	:	DDS
Telephone Number	:	951-785-4200

Provider Enumeration Date	:	10/02/2007
Last Update Date	:	10/10/2007

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