MEDICARE: NELSON JAVIAR DIAZ DMD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	DN16154	FL

General Provider Information

NPI Number	:	1093747917
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NELSON JAVIAR DIAZ DMD

Provider Business Mailing Address
First Line	:	926 GREAT POND DR
Second Line	:	SUITE 2003
City	:	ALTAMONTE SPRINGS
State	:	FL
Zip	:	32714-7244
Country	:	US
Telephone Number	:	407-772-5124
Fax Number	:

Provider Business Practice Location Address
First Line	:	5316 CENTRAL FLORIDA PKWY
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32821-8772
Country	:	US
Telephone Number	:	407-239-9557
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/07/2006
Last Update Date	:	07/08/2007

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