Healthcare Provider Details

I. General information

NPI: 1629686787
Provider Name (Legal Business Name): VIVIAN DIAZ BDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2020
Last Update Date: 07/15/2020
Certification Date: 07/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1395 CENTER DR RM D8-18B
GAINESVILLE FL
32610-3006
US

IV. Provider business mailing address

1777 SW 72ND CIR
GAINESVILLE FL
32607-1021
US

V. Phone/Fax

Practice location:
  • Phone: 805-428-4577
  • Fax:
Mailing address:
  • Phone: 805-428-4577
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0008X
TaxonomyOral and Maxillofacial Radiology Dentistry
License NumberDRPM2169
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: