MEDICARE: DR. SEBASTIAN GONZALEZ-DIAZ DMD

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	6945	LA

General Provider Information

NPI Number	:	1609333178
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SEBASTIAN GONZALEZ-DIAZ DMD

Provider Business Mailing Address
First Line	:	3709 MASONIC DR
Second Line	:
City	:	ALEXANDRIA
State	:	LA
Zip	:	71301-3632
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3709 MASONIC DR
Second Line	:
City	:	ALEXANDRIA
State	:	LA
Zip	:	71301-3632
Country	:	US
Telephone Number	:	318-553-5318
Fax Number	:

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

Provider Enumeration Date	:	02/20/2019
Last Update Date	:	02/20/2019

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