Provider Demographics
NPI:1821223934
Name:EDUARDO DIAZ DENTAL CORPORATION
Entity Type:Organization
Organization Name:EDUARDO DIAZ DENTAL CORPORATION
Other - Org Name:EASTLAKE IMPLANT & LASER DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:EDUARDO
Authorized Official - Middle Name:
Authorized Official - Last Name:DIAZ
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, PC, ICOI
Authorized Official - Phone:619-216-0111
Mailing Address - Street 1:890 EASTLAKE PKWY
Mailing Address - Street 2:SUITE 303
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91914-4520
Mailing Address - Country:US
Mailing Address - Phone:619-216-0111
Mailing Address - Fax:619-216-7081
Practice Address - Street 1:890 EASTLAKE PKWY
Practice Address - Street 2:SUITE 303
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91914-4520
Practice Address - Country:US
Practice Address - Phone:619-216-0111
Practice Address - Fax:619-216-7081
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-18
Last Update Date:2011-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA44306261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1922157288OtherNPI
CA=========OtherTAX ID
CA1922157288OtherNPI
CA=========OtherTAX ID