Provider Demographics
NPI:1285612358
Name:DIAZ, JORGE L (DDS)
Entity type:Individual
Prefix:DR
First Name:JORGE
Middle Name:L
Last Name:DIAZ
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8720 N KENDALL DR
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33176-2198
Mailing Address - Country:US
Mailing Address - Phone:305-279-6868
Mailing Address - Fax:305-279-6869
Practice Address - Street 1:8720 N KENDALL DR
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33176-2198
Practice Address - Country:US
Practice Address - Phone:305-279-6868
Practice Address - Fax:305-279-6869
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN0128851223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice