Provider Demographics
NPI:1619360716
Name:GONZALEZ DIAZ, ERNESTO
Entity type:Individual
Prefix:
First Name:ERNESTO
Middle Name:
Last Name:GONZALEZ 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 1:107 SARTO AVE
Mailing Address - Street 2:
Mailing Address - City:CORAL GABLES
Mailing Address - State:FL
Mailing Address - Zip Code:33134-7247
Mailing Address - Country:US
Mailing Address - Phone:786-317-3321
Mailing Address - Fax:
Practice Address - Street 1:701 N FEDERAL HWY STE 210
Practice Address - Street 2:
Practice Address - City:HALLANDALE BEACH
Practice Address - State:FL
Practice Address - Zip Code:33009-2451
Practice Address - Country:US
Practice Address - Phone:954-998-2099
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-13
Last Update Date:2024-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL230041223G0001X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice