Provider Demographics
NPI:1740496892
Name:DIAZ, JESUS ANTONIO (DDS)
Entity type:Individual
Prefix:DR
First Name:JESUS
Middle Name:ANTONIO
Last Name:DIAZ
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1402 SE 17TH AVE
Mailing Address - Street 2:
Mailing Address - City:HOMESTEAD
Mailing Address - State:FL
Mailing Address - Zip Code:33035-2211
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7000 W 12TH AVE
Practice Address - Street 2:SUITE 6
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33014-5154
Practice Address - Country:US
Practice Address - Phone:305-557-5888
Practice Address - Fax:305-818-6677
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-15
Last Update Date:2021-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN117991223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics