Provider Demographics
NPI:1063184653
Name:DIAZ, RAQUEL (RDH)
Entity type:Individual
Prefix:
First Name:RAQUEL
Middle Name:
Last Name:DIAZ
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3277 COUNTRY HILL RD
Mailing Address - Street 2:
Mailing Address - City:SEBRING
Mailing Address - State:FL
Mailing Address - Zip Code:33872-3346
Mailing Address - Country:US
Mailing Address - Phone:863-441-4602
Mailing Address - Fax:
Practice Address - Street 1:901 US HIGHWAY 27 N STE 60
Practice Address - Street 2:
Practice Address - City:SEBRING
Practice Address - State:FL
Practice Address - Zip Code:33870-2129
Practice Address - Country:US
Practice Address - Phone:863-471-1176
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-01
Last Update Date:2021-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDH22461124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist