Provider Demographics
NPI:1942232871
Name:DIAZ, LUIS JOSE (DMD)
Entity Type:Individual
Prefix:DR
First Name:LUIS
Middle Name:JOSE
Last Name:DIAZ
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1305 AVE MAGDALENA
Mailing Address - Street 2:APT. 501
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00907-1929
Mailing Address - Country:US
Mailing Address - Phone:787-565-8819
Mailing Address - Fax:
Practice Address - Street 1:400 F.D. ROOSEVELT AVE
Practice Address - Street 2:SUITE 503
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00918-1929
Practice Address - Country:US
Practice Address - Phone:787-756-5300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR25901223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery