Provider Demographics
NPI:1891951067
Name:DIAZ, RODOLFO (DDS, MS)
Entity Type:Individual
Prefix:
First Name:RODOLFO
Middle Name:
Last Name:DIAZ
Suffix:
Gender:M
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5050 SCHAEFER RD
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48126-3249
Mailing Address - Country:US
Mailing Address - Phone:313-582-8150
Mailing Address - Fax:313-582-6015
Practice Address - Street 1:32750 GRAND RIVER AVE
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:MI
Practice Address - Zip Code:48336-3133
Practice Address - Country:US
Practice Address - Phone:248-476-6200
Practice Address - Fax:248-476-4642
Is Sole Proprietor?:No
Enumeration Date:2008-08-06
Last Update Date:2008-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901019304122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist