Provider Demographics
NPI:1770707937
Name:BARAJAS, DIANA MALO (DDS)
Entity type:Individual
Prefix:DR
First Name:DIANA
Middle Name:MALO
Last Name:BARAJAS
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1527 SE 16TH PL
Mailing Address - Street 2:
Mailing Address - City:CAPE CORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33990-6845
Mailing Address - Country:US
Mailing Address - Phone:239-772-5005
Mailing Address - Fax:239-772-4929
Practice Address - Street 1:12561 GEMSTONE CT
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33913-6730
Practice Address - Country:US
Practice Address - Phone:239-245-7547
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN 178491223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice