MEDICARE: MS. CARMEN MARIE DIAZ RDA

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	126800000X	Dental Assistant	D160049121	WA
2	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1144551003
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. CARMEN MARIE DIAZ RDA

Provider Business Mailing Address
First Line	:	7241 S MONROE ST
Second Line	:
City	:	TACOMA
State	:	WA
Zip	:	98409-2445
Country	:	US
Telephone Number	:	253-678-2564
Fax Number	:

Provider Business Practice Location Address
First Line	:	7241 S MONROE ST
Second Line	:
City	:	TACOMA
State	:	WA
Zip	:	98409-2445
Country	:	US
Telephone Number	:	253-678-2564
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/15/2010
Last Update Date	:	01/15/2010

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