Provider Demographics
NPI:1487092631
Name:DIAZ, LOURDES F (DDS)
Entity type:Individual
Prefix:DR
First Name:LOURDES
Middle Name:F
Last Name:DIAZ
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24541 PACIFIC PARK DR STE 105
Mailing Address - Street 2:
Mailing Address - City:ALISO VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92656-3050
Mailing Address - Country:US
Mailing Address - Phone:949-643-7047
Mailing Address - Fax:949-643-7049
Practice Address - Street 1:24541 PACIFIC PARK DR STE 105
Practice Address - Street 2:
Practice Address - City:ALISO VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92656-3050
Practice Address - Country:US
Practice Address - Phone:949-643-7047
Practice Address - Fax:949-643-7049
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-10
Last Update Date:2013-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA523731223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice