Provider Demographics
NPI:1194455329
Name:PEREZ, DIANA (DMD)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:
Last Name:PEREZ
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17776 NW 57TH AVE
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33015-5118
Mailing Address - Country:US
Mailing Address - Phone:786-587-8540
Mailing Address - Fax:
Practice Address - Street 1:17776 NW 57TH AVE
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33015-5118
Practice Address - Country:US
Practice Address - Phone:786-587-8540
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-11
Last Update Date:2022-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL5690029391223G0001X
FLDN270221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty