Provider Demographics
NPI:1407697931
Name:DIAZ QUEVEDO, SONIA DEL CARMEN (DMD)
Entity type:Individual
Prefix:
First Name:SONIA
Middle Name:DEL CARMEN
Last Name:DIAZ QUEVEDO
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9520 KONA VILLAGE DR APT 308
Mailing Address - Street 2:
Mailing Address - City:RIVERVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:33578-5206
Mailing Address - Country:US
Mailing Address - Phone:786-915-9705
Mailing Address - Fax:
Practice Address - Street 1:724 LITHIA PINECREST RD
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-6117
Practice Address - Country:US
Practice Address - Phone:813-685-6139
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-06
Last Update Date:2024-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL290321223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice