Healthcare Provider Details

I. General information

NPI: 1902571078
Provider Name (Legal Business Name): CORY AUSTIN DIAZ DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/11/2021
Last Update Date: 08/11/2021
Certification Date: 08/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

520 POPE AVE
FORT LEAVENWORTH KS
66027-2332
US

IV. Provider business mailing address

15217 WOODSON ST
OVERLAND PARK KS
66223-3249
US

V. Phone/Fax

Practice location:
  • Phone: 913-684-5516
  • Fax:
Mailing address:
  • Phone: 714-875-5800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number61924
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: