Provider Demographics
NPI:1932244894
Name:DIAZ, RAFAEL AGUSTIN (DMD)
Entity Type:Individual
Prefix:DR
First Name:RAFAEL
Middle Name:AGUSTIN
Last Name:DIAZ
Suffix:
Gender:M
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 578
Mailing Address - Street 2:
Mailing Address - City:LUQUILLO
Mailing Address - State:PR
Mailing Address - Zip Code:00773-0578
Mailing Address - Country:US
Mailing Address - Phone:787-889-2820
Mailing Address - Fax:787-889-2820
Practice Address - Street 1:308 CALLE FERNANDEZ GARCIA
Practice Address - Street 2:
Practice Address - City:LUQUILLO
Practice Address - State:PR
Practice Address - Zip Code:00773-2233
Practice Address - Country:US
Practice Address - Phone:787-889-2820
Practice Address - Fax:787-889-2820
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR11091223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice