Provider Demographics
NPI:1558049387
Name:FERNANDEZ VIAL, DIEGO IGNACIO (DDS MS)
Entity Type:Individual
Prefix:
First Name:DIEGO
Middle Name:IGNACIO
Last Name:FERNANDEZ VIAL
Suffix:
Gender:M
Credentials:DDS MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1916 W GRAY ST APT 240
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77019-4834
Mailing Address - Country:US
Mailing Address - Phone:859-382-3910
Mailing Address - Fax:
Practice Address - Street 1:12626 WOODFOREST BLVD STE Z
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77015-3653
Practice Address - Country:US
Practice Address - Phone:171-359-0099
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-11
Last Update Date:2023-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX398101223X2210X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X2210XDental ProvidersDentistOrofacial Pain