Provider Demographics
NPI:1346465317
Name:DAVID M. DIAZ DENTAL CORPORATION
Entity Type:Organization
Organization Name:DAVID M. DIAZ DENTAL CORPORATION
Other - Org Name:REDLANDS CHILDRENS DENTAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:M
Authorized Official - Last Name:DIAZ
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:909-798-2755
Mailing Address - Street 1:1801 NEWPORT BLVD
Mailing Address - Street 2:
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92627
Mailing Address - Country:US
Mailing Address - Phone:949-548-5588
Mailing Address - Fax:
Practice Address - Street 1:308 W STATE ST STE 4A
Practice Address - Street 2:
Practice Address - City:REDLANDS
Practice Address - State:CA
Practice Address - Zip Code:92373-4626
Practice Address - Country:US
Practice Address - Phone:909-798-2755
Practice Address - Fax:909-307-2098
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-16
Last Update Date:2007-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA306421223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty