Provider Demographics
NPI:1962681882
Name:DIAZ, PATRICIA ALEJANDRA (DDS, MS)
Entity Type:Individual
Prefix:DR
First Name:PATRICIA
Middle Name:ALEJANDRA
Last Name:DIAZ
Suffix:
Gender:F
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 1:29627 FORD RD.
Mailing Address - Street 2:
Mailing Address - City:GARDEN CITY
Mailing Address - State:MI
Mailing Address - Zip Code:48135
Mailing Address - Country:US
Mailing Address - Phone:734-422-2890
Mailing Address - Fax:734-422-2891
Practice Address - Street 1:29627 FORD RD.
Practice Address - Street 2:
Practice Address - City:GARDEN CITY
Practice Address - State:MI
Practice Address - Zip Code:48135
Practice Address - Country:US
Practice Address - Phone:734-422-2890
Practice Address - Fax:734-422-2891
Is Sole Proprietor?:No
Enumeration Date:2007-10-27
Last Update Date:2020-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010206031223P0300X, 1223G0001X
TX202831223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX150557301Medicaid