Provider Demographics
NPI:1659536043
Name:BLANCO, DIANA ROSA (DMD)
Entity Type:Individual
Prefix:DR
First Name:DIANA
Middle Name:ROSA
Last Name:BLANCO
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 1:401 MIRACLE MILE
Mailing Address - Street 2:SUITE 209
Mailing Address - City:CORAL GABLES
Mailing Address - State:FL
Mailing Address - Zip Code:33134
Mailing Address - Country:US
Mailing Address - Phone:305-456-4592
Mailing Address - Fax:786-360-6953
Practice Address - Street 1:401 MIRACLE MILE
Practice Address - Street 2:SUITE 209
Practice Address - City:CORAL GABLES
Practice Address - State:FL
Practice Address - Zip Code:33134
Practice Address - Country:US
Practice Address - Phone:305-456-4592
Practice Address - Fax:786-360-6953
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-24
Last Update Date:2010-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN184711223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice