Provider Demographics
NPI:1245560028
Name:DIAZ, VIVIAN ELENA (DMD)
Entity Type:Individual
Prefix:DR
First Name:VIVIAN
Middle Name:ELENA
Last Name:DIAZ
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 1:8531 SW 94TH AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33173-4512
Mailing Address - Country:US
Mailing Address - Phone:305-781-1548
Mailing Address - Fax:
Practice Address - Street 1:7150 W 20TH AVE
Practice Address - Street 2:SUITE 102
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33016-5529
Practice Address - Country:US
Practice Address - Phone:305-556-3313
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-12-30
Last Update Date:2009-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN188961223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice