Basic Information
| Provider Information | |||||||||
| NPI: | 1639370737 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DAVID M. DIAZ, DDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1801 NEWPORT BLVD | ||||||||
| Address2: | SUITE B | ||||||||
| City: | COSTA MESA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926272701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9495485588 | ||||||||
| FaxNumber: | 9495485731 | ||||||||
| Practice Location | |||||||||
| Address1: | 1801 NEWPORT BLVD STE B | ||||||||
| Address2: | |||||||||
| City: | COSTA MESA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926272701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9495485588 | ||||||||
| FaxNumber: | 9495485731 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/29/2007 | ||||||||
| LastUpdateDate: | 05/21/2020 | ||||||||
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| AuthorizedOfficialLastName: | BATTISTA | ||||||||
| AuthorizedOfficialFirstName: | TERESA | ||||||||
| AuthorizedOfficialMiddleName: | D. | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 9495485588 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 30642 | CA | Y | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist |
ID Information
| ID | Type | State | Issuer | Description | $$$$$$$$$ | 01 | CA | SOCIAL SECURITY NUMBER | OTHER |