Provider Demographics
NPI:1538259254
Name:DIAZ, RICARDO (DDS, MS)
Entity type:Individual
Prefix:DR
First Name:RICARDO
Middle Name:
Last Name:DIAZ
Suffix:
Gender:M
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4871 FREDERICKSBURG RD
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78229
Mailing Address - Country:US
Mailing Address - Phone:210-349-5553
Mailing Address - Fax:210-349-5844
Practice Address - Street 1:4871 FREDERICKSBURG RD
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229
Practice Address - Country:US
Practice Address - Phone:210-349-5553
Practice Address - Fax:210-349-5844
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2009-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX144881223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics