Provider Demographics
NPI:1710052295
Name:DIAZ, ROBERTO (DDS)
Entity Type:Individual
Prefix:DR
First Name:ROBERTO
Middle Name:
Last Name: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 1:1501 W SAM HOUSTON ST
Mailing Address - Street 2:
Mailing Address - City:PHARR
Mailing Address - State:TX
Mailing Address - Zip Code:78577-5111
Mailing Address - Country:US
Mailing Address - Phone:956-781-5477
Mailing Address - Fax:956-781-4878
Practice Address - Street 1:1501 W SAM HOUSTON ST
Practice Address - Street 2:
Practice Address - City:PHARR
Practice Address - State:TX
Practice Address - Zip Code:78577-5111
Practice Address - Country:US
Practice Address - Phone:956-781-5477
Practice Address - Fax:956-781-4878
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX134491223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice