Provider Demographics
NPI:1457406803
Name:DIAZ, MARIA CARMEN (DMD)
Entity Type:Individual
Prefix:DR
First Name:MARIA
Middle Name:CARMEN
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:PO BOX 748
Mailing Address - Street 2:
Mailing Address - City:CAGUAS
Mailing Address - State:PR
Mailing Address - Zip Code:00726-0748
Mailing Address - Country:US
Mailing Address - Phone:787-745-2005
Mailing Address - Fax:787-745-2005
Practice Address - Street 1:48 GOYCO ST.
Practice Address - Street 2:
Practice Address - City:CAGUAS
Practice Address - State:PR
Practice Address - Zip Code:00725
Practice Address - Country:US
Practice Address - Phone:787-745-2005
Practice Address - Fax:787-745-2005
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR17521223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice