Basic Information
| Provider Information | |||||||||
| NPI: | 1356912562 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DIAZ | ||||||||
| FirstName: | VANESSA | ||||||||
| MiddleName: | MELISSA | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DMD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1800 NW 24TH AVE APT 412 | ||||||||
| Address2: | |||||||||
| City: | MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331251236 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7865460552 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 10430 PINES BLVD STE C103 | ||||||||
| Address2: | |||||||||
| City: | PEMBROKE PINES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330266049 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9542510238 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/08/2021 | ||||||||
| LastUpdateDate: | 07/08/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 07/08/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | DN26051 | FL | Y | Dental Providers | Dentist |
No ID Information.