Provider Demographics
NPI:1134487325
Name:DIAZ, BERTHA (RDAEF)
Entity Type:Individual
Prefix:MRS
First Name:BERTHA
Middle Name:
Last Name:DIAZ
Suffix:
Gender:F
Credentials:RDAEF
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:160 CAPP ST
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94110-1210
Mailing Address - Country:US
Mailing Address - Phone:415-621-8056
Mailing Address - Fax:415-621-1429
Practice Address - Street 1:160 CAPP ST
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94110-1210
Practice Address - Country:US
Practice Address - Phone:415-621-8056
Practice Address - Fax:415-621-1429
Is Sole Proprietor?:No
Enumeration Date:2012-04-25
Last Update Date:2012-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAEF 330126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant