Provider Demographics
NPI:1902571078
Name:DIAZ, CORY AUSTIN (DDS)
Entity Type:Individual
Prefix:DR
First Name:CORY
Middle Name:AUSTIN
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 1:15217 WOODSON ST
Mailing Address - Street 2:
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66223-3249
Mailing Address - Country:US
Mailing Address - Phone:714-875-5800
Mailing Address - Fax:
Practice Address - Street 1:520 POPE AVE
Practice Address - Street 2:
Practice Address - City:FORT LEAVENWORTH
Practice Address - State:KS
Practice Address - Zip Code:66027-2332
Practice Address - Country:US
Practice Address - Phone:913-684-5516
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-11
Last Update Date:2021-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS619241223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice