Provider Demographics
NPI:1740206176
Name:DIAZ, DENNIS MARK (DC)
Entity Type:Individual
Prefix:DR
First Name:DENNIS
Middle Name:MARK
Last Name:DIAZ
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2624 SUNSET DR
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501-3443
Mailing Address - Country:US
Mailing Address - Phone:208-743-0472
Mailing Address - Fax:
Practice Address - Street 1:2624 SUNSET DR
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-3443
Practice Address - Country:US
Practice Address - Phone:208-743-0472
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCHIA-429111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor