Healthcare Provider Details

I. General information

NPI: 1225529464
Provider Name (Legal Business Name): CARLOS LOPEZ DIAZ DDS DENTAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/23/2018
Last Update Date: 05/23/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19046 LA PUENTE RD
WEST COVINA CA
91792
US

IV. Provider business mailing address

19046 LA PUENTE RD
WEST COVINA CA
91792
US

V. Phone/Fax

Practice location:
  • Phone: 626-200-1900
  • Fax:
Mailing address:
  • Phone: 626-200-1900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number101712
License Number StateCA

VIII. Authorized Official

Name: DR. CARLOS LOPEZ DIAZ
Title or Position: PRESIDENT
Credential: DDS
Phone: 226-200-1900