Healthcare Provider Details

I. General information

NPI: 1285742189
Provider Name (Legal Business Name): RAFAEL DIAZ MENDEZ DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/29/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 AVE FD ROOSEVELT SUITE 502
SAN JUAN PR
00918
US

IV. Provider business mailing address

A17 CALLE PALMA SOLA GARDEN HILLS SUR
GUAYNABO PR
00966-2923
US

V. Phone/Fax

Practice location:
  • Phone: 787-756-5252
  • Fax: 787-763-4928
Mailing address:
  • Phone: 787-781-0281
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number1052
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: