Basic Information
| Provider Information | |||||||||
| NPI: | 1548347016 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DIAZ | ||||||||
| FirstName: | LUIS | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DMD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4450 S TIFFANY DR | ||||||||
| Address2: | |||||||||
| City: | WEST PALM BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334073241 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5618449443 | ||||||||
| FaxNumber: | 5618441013 | ||||||||
| Practice Location | |||||||||
| Address1: | 2015 US HIGHWAY 441 N | ||||||||
| Address2: | |||||||||
| City: | OKEECHOBEE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 349721901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8637631951 | ||||||||
| FaxNumber: | 8633572991 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/01/2006 | ||||||||
| LastUpdateDate: | 05/26/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 9421 | FL | Y | Dental Providers | Dentist | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 001434400 | 05 | FL | MEDICAID |