Healthcare Provider Details

I. General information

NPI: 1144551003
Provider Name (Legal Business Name): CARMEN MARIE DIAZ RDA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/15/2010
Last Update Date: 01/15/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7241 S MONROE ST
TACOMA WA
98409-2445
US

IV. Provider business mailing address

7241 S MONROE ST
TACOMA WA
98409-2445
US

V. Phone/Fax

Practice location:
  • Phone: 253-678-2564
  • Fax:
Mailing address:
  • Phone: 253-678-2564
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code126800000X
TaxonomyDental Assistant
License NumberD160049121
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: