Healthcare Provider Details

I. General information

NPI: 1780521625
Provider Name (Legal Business Name): ANDREA DIAZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/29/2026
Last Update Date: 04/29/2026
Certification Date: 04/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 THE PKWY STE F
GREER SC
29650-5221
US

IV. Provider business mailing address

326 MILLBANK RD
WELLFORD SC
29385-9658
US

V. Phone/Fax

Practice location:
  • Phone: 515-491-3050
  • Fax:
Mailing address:
  • Phone: 515-491-3050
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code126800000X
TaxonomyDental Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: