Provider Demographics
NPI:1952706087
Name:DIAZ SANCHEZ, ANTONIO
Entity Type:Individual
Prefix:DR
First Name:ANTONIO
Middle Name:
Last Name:DIAZ SANCHEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7606 S FULTON PARK BLVD
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97219-2926
Mailing Address - Country:US
Mailing Address - Phone:805-801-7883
Mailing Address - Fax:
Practice Address - Street 1:4342 LIBERTY RD S
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97302-6171
Practice Address - Country:US
Practice Address - Phone:503-363-6500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-31
Last Update Date:2020-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA63651122300000X
ORD112341223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty
No122300000XDental ProvidersDentist