Provider Demographics
NPI:1891362067
Name:DIAZ, MADISON (DDS)
Entity Type:Individual
Prefix:
First Name:MADISON
Middle Name:
Last Name:DIAZ
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4911 MERCIER ST
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64112-1308
Mailing Address - Country:US
Mailing Address - Phone:913-633-0061
Mailing Address - Fax:
Practice Address - Street 1:811 S BUSINESS HIGHWAY 13 STE A
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:MO
Practice Address - Zip Code:64067-1572
Practice Address - Country:US
Practice Address - Phone:660-251-6440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-07
Last Update Date:2024-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20210194901223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice