Provider Demographics
NPI:1619132057
Name:SERVAN DIAZ, EDUARDO WILLINGTON (DDS)
Entity Type:Individual
Prefix:DR
First Name:EDUARDO
Middle Name:WILLINGTON
Last Name:SERVAN DIAZ
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6615 SEVILLE AVE
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON PARK
Mailing Address - State:CA
Mailing Address - Zip Code:90255-4801
Mailing Address - Country:US
Mailing Address - Phone:323-581-1010
Mailing Address - Fax:323-581-7598
Practice Address - Street 1:6615 SEVILLE AVE
Practice Address - Street 2:
Practice Address - City:HUNTINGTON PARK
Practice Address - State:CA
Practice Address - Zip Code:90255-4801
Practice Address - Country:US
Practice Address - Phone:323-581-1010
Practice Address - Fax:323-581-7598
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-24
Last Update Date:2014-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA573211223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice