Provider Demographics
NPI:1609333178
Name:GONZALEZ-DIAZ, SEBASTIAN (DMD)
Entity Type:Individual
Prefix:DR
First Name:SEBASTIAN
Middle Name:
Last Name:GONZALEZ-DIAZ
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 1:3709 MASONIC DR
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:LA
Mailing Address - Zip Code:71301-3632
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3709 MASONIC DR
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:LA
Practice Address - Zip Code:71301-3632
Practice Address - Country:US
Practice Address - Phone:318-553-5318
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-20
Last Update Date:2019-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA69451223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice