Provider Demographics
NPI:1932755758
Name:DIAS, DAVID ANTHONY (LAC)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:ANTHONY
Last Name:DIAS
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112 DAVENPORT AVE
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07107-1921
Mailing Address - Country:US
Mailing Address - Phone:973-432-8134
Mailing Address - Fax:
Practice Address - Street 1:112 DAVENPORT AVE
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07107-1921
Practice Address - Country:US
Practice Address - Phone:973-432-8134
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-16
Last Update Date:2019-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MZ00141200171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist