Provider Demographics
NPI:1922260983
Name:DIAZ, ROSA IDALIA (DENTIST)
Entity Type:Individual
Prefix:DR
First Name:ROSA
Middle Name:IDALIA
Last Name:DIAZ
Suffix:
Gender:F
Credentials:DENTIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:90 AMSTERDAM AVE
Mailing Address - Street 2:APT #10F
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10023-7431
Mailing Address - Country:US
Mailing Address - Phone:718-602-5200
Mailing Address - Fax:
Practice Address - Street 1:PROFESSIONAL DENTAL OFFICE PC
Practice Address - Street 2:1323 MYRTLE AVE
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11221
Practice Address - Country:US
Practice Address - Phone:718-602-5200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-30
Last Update Date:2008-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY048431-1122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist