Healthcare Provider Details

I. General information

NPI: 1205745759
Provider Name (Legal Business Name): KELSEY DIAZ DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/02/2026
Last Update Date: 09/02/2026
Certification Date: 09/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7839 IDLEWILD RD
CHARLOTTE NC
28212-5845
US

IV. Provider business mailing address

5009 HEMBY RD
MATTHEWS NC
28104-7712
US

V. Phone/Fax

Practice location:
  • Phone: 704-778-1204
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number11560
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number14760
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: