Provider Demographics
NPI:1821465170
Name:DIAZ, JOSSEELAINE (RDH)
Entity Type:Individual
Prefix:
First Name:JOSSEELAINE
Middle Name:
Last Name:DIAZ
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1302 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06706-1748
Mailing Address - Country:US
Mailing Address - Phone:203-756-8021
Mailing Address - Fax:203-596-9038
Practice Address - Street 1:80 PHOENIX AVE
Practice Address - Street 2:
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06702-1418
Practice Address - Country:US
Practice Address - Phone:203-756-8021
Practice Address - Fax:203-597-8860
Is Sole Proprietor?:No
Enumeration Date:2015-08-21
Last Update Date:2015-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT008430124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist