Provider Demographics
NPI:1760406706
Name:DIAZ, RICHARD NELSON (DDS)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:NELSON
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 1:2716 WOLFE DR
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21758-8802
Mailing Address - Country:US
Mailing Address - Phone:301-834-8781
Mailing Address - Fax:
Practice Address - Street 1:115 S CHARLES ST
Practice Address - Street 2:
Practice Address - City:CHARLES TOWN
Practice Address - State:WV
Practice Address - Zip Code:25414
Practice Address - Country:US
Practice Address - Phone:304-725-4492
Practice Address - Fax:304-725-9700
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2018-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD84122300000X
WV25711223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0136653000Medicaid