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General NPI Number Information
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NPI Number | 1346465317
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Entity Type | Organization
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Legal Business Name | DAVID M. DIAZ DENTAL CORPORATION
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Dates
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Enumeration Date | 04/16/2007
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Last Update Date | 09/19/2007
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Provider Practice Location Address
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Address Line | 308 W STATE ST STE 4A
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City | REDLANDS
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State | CA
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Zip | 92373-4626
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Country | US
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Telephone | 909-798-2755
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Fax | 909-307-2098
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Provider Business Mailing Address
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Address Line | 1801 NEWPORT BLVD
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City | COSTA MESA
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State | CA
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Zip | 92627
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Country | US
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Telephone | 949-548-5588
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. DAVID M DIAZ
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Credential | D.D.S.
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Telephone | 909-798-2755
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0221X
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Taxonomy Name | Pediatric Dentistry
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License Number | 30642
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License Number State | CA
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