Healthcare Provider Details

I. General information

NPI: 1043392111
Provider Name (Legal Business Name): FEDERICO DIEZ D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/19/2006
Last Update Date: 09/29/2021
Certification Date: 09/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12600 PEMBROKE RD SUITE 314
MIRAMAR FL
33027-2544
US

IV. Provider business mailing address

4581 WESTON RD # 321
WESTON FL
33331-3141
US

V. Phone/Fax

Practice location:
  • Phone: 954-505-7631
  • Fax: 954-505-7633
Mailing address:
  • Phone: 305-725-3426
  • Fax: 954-517-1592

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN 14284
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number14284
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: