Healthcare Provider Details

I. General information

NPI: 1003803693
Provider Name (Legal Business Name): MAGDA S. DIAZ D.M.D
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/29/2005
Last Update Date: 01/07/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

38 CALLE BETANCES CLINICA DENTAL AYMAT
VEGA BAJA PR
00693-4453
US

IV. Provider business mailing address

PO BOX 54 290 AVE. SANTA ANA TORRIMAR TOWN PARK
GUAYNABO PR
00970-0054
US

V. Phone/Fax

Practice location:
  • Phone: 787-855-3996
  • Fax:
Mailing address:
  • Phone: 787-504-4126
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number2656
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: