Healthcare Provider Details

I. General information

NPI: 1487233664
Provider Name (Legal Business Name): GABRIELLA DANIELLE DIAZ DDS, MSD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2021
Last Update Date: 12/07/2022
Certification Date: 12/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5419 FREDERICKSBURG RD
SAN ANTONIO TX
78229-3503
US

IV. Provider business mailing address

11215 ANAQUA SPGS
BOERNE TX
78006-8493
US

V. Phone/Fax

Practice location:
  • Phone: 210-616-0980
  • Fax:
Mailing address:
  • Phone: 817-300-6658
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number35975
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: