Provider Demographics
NPI:1295298842
Name:DIAZ, THELMA SUSETTE
Entity type:Individual
Prefix:
First Name:THELMA
Middle Name:SUSETTE
Last Name:DIAZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2999 NE 191ST ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33180-3123
Mailing Address - Country:US
Mailing Address - Phone:305-682-1795
Mailing Address - Fax:305-974-2661
Practice Address - Street 1:2999 NE 191ST ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33180-3123
Practice Address - Country:US
Practice Address - Phone:305-682-1795
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-10
Last Update Date:2021-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL26401122300000X
PR390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No122300000XDental ProvidersDentist