Provider Demographics
NPI:1578249694
Name:DIAZ, AMY (DMD)
Entity Type:Individual
Prefix:DR
First Name:AMY
Middle Name:
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 1:510 BEATTIE ST
Mailing Address - Street 2:
Mailing Address - City:ELWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60421-9783
Mailing Address - Country:US
Mailing Address - Phone:779-875-9600
Mailing Address - Fax:
Practice Address - Street 1:4130 W JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60431-4720
Practice Address - Country:US
Practice Address - Phone:815-744-4333
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-23
Last Update Date:2023-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.0343321223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice