Provider Demographics
NPI:1952086340
Name:CONSUEGRA DIAZ, RENE MIGUEL (DDS)
Entity Type:Individual
Prefix:DR
First Name:RENE
Middle Name:MIGUEL
Last Name:CONSUEGRA 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 1:4400 W 16TH AVE APT 428
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33012-7106
Mailing Address - Country:US
Mailing Address - Phone:786-230-0215
Mailing Address - Fax:
Practice Address - Street 1:4400 W 16TH AVE APT 428
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33012-7106
Practice Address - Country:US
Practice Address - Phone:786-230-0215
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-21
Last Update Date:2023-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN28175122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist