Provider Demographics
NPI:1003921099
Name:DIAZ, MARCOS (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARCOS
Middle Name:
Last Name:DIAZ
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2239 N COMMERCE PKWY
Mailing Address - Street 2:SUITE #2
Mailing Address - City:WESTON
Mailing Address - State:FL
Mailing Address - Zip Code:33326-3249
Mailing Address - Country:US
Mailing Address - Phone:954-659-9990
Mailing Address - Fax:
Practice Address - Street 1:2239 N COMMERCE PKWY
Practice Address - Street 2:SUITE #2
Practice Address - City:WESTON
Practice Address - State:FL
Practice Address - Zip Code:33326-3249
Practice Address - Country:US
Practice Address - Phone:954-659-9990
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN00132931223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLU51539Medicare UPIN