Provider Demographics
NPI:1881613602
Name:DIAZ, MICHAEL SR (DDS)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:
Last Name:DIAZ
Suffix:SR
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 1:242 E AIRPORT DR STE 100
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92408-3408
Mailing Address - Country:US
Mailing Address - Phone:909-890-0050
Mailing Address - Fax:909-890-0042
Practice Address - Street 1:242 E AIRPORT DR STE 100
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92408-3408
Practice Address - Country:US
Practice Address - Phone:909-890-0050
Practice Address - Fax:909-890-0042
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-19
Last Update Date:2015-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA300611223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice