Provider Demographics
NPI:1184305880
Name:DIAZ, JENNIFER C (DMD)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:C
Last Name:DIAZ
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:263 DAVIS ST
Mailing Address - Street 2:
Mailing Address - City:SAN LEANDRO
Mailing Address - State:CA
Mailing Address - Zip Code:94577-2742
Mailing Address - Country:US
Mailing Address - Phone:510-357-8878
Mailing Address - Fax:510-357-8898
Practice Address - Street 1:263 DAVIS ST
Practice Address - Street 2:
Practice Address - City:SAN LEANDRO
Practice Address - State:CA
Practice Address - Zip Code:94577-2742
Practice Address - Country:US
Practice Address - Phone:510-861-3471
Practice Address - Fax:510-357-8898
Is Sole Proprietor?:No
Enumeration Date:2023-07-26
Last Update Date:2023-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA48254122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist