Provider Demographics
NPI:1497197271
Name:CAMACHO, DIEGO A (DMD)
Entity Type:Individual
Prefix:DR
First Name:DIEGO
Middle Name:A
Last Name:CAMACHO
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3037 E COMMERCIAL BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33308-4311
Mailing Address - Country:US
Mailing Address - Phone:954-772-3600
Mailing Address - Fax:954-772-3663
Practice Address - Street 1:3037 E COMMERCIAL BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33308-4311
Practice Address - Country:US
Practice Address - Phone:954-772-3600
Practice Address - Fax:954-772-3663
Is Sole Proprietor?:No
Enumeration Date:2013-07-22
Last Update Date:2016-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04420001901223P0300X
FLDN222361223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics