=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295093755
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARIA V DIAZ DMD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/02/2012
-----------------------------------------------------
Last Update Date | 07/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 14729 FERRARA CT
-----------------------------------------------------
City | BONITA SPRINGS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34135-8294
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 239-221-7110
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 51992
-----------------------------------------------------
City | TOA BAJA
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00950-1992
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-269-1442
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0300X
-----------------------------------------------------
Taxonomy Name | Periodontics
-----------------------------------------------------
License Number | DN22329
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------