Healthcare Provider Details

I. General information

NPI: 1093747917
Provider Name (Legal Business Name): NELSON JAVIAR DIAZ DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5316 CENTRAL FLORIDA PKWY
ORLANDO FL
32821-8772
US

IV. Provider business mailing address

926 GREAT POND DR SUITE 2003
ALTAMONTE SPRINGS FL
32714-7244
US

V. Phone/Fax

Practice location:
  • Phone: 407-239-9557
  • Fax:
Mailing address:
  • Phone: 407-772-5124
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberDN16154
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: