Provider Demographics
NPI:1699473637
Name:DIAZ, MARCOS
Entity type:Individual
Prefix:
First Name:MARCOS
Middle Name:
Last Name:DIAZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6101 LAKE ELLENOR DR
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32809-4616
Mailing Address - Country:US
Mailing Address - Phone:407-858-1400
Mailing Address - Fax:407-858-5529
Practice Address - Street 1:5449 S SEMORAN BLVD STE 19B
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32822-1778
Practice Address - Country:US
Practice Address - Phone:407-723-5264
Practice Address - Fax:407-249-4472
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-20
Last Update Date:2023-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDH29865124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLDH29865OtherMEDICAL LICENSE