Provider Demographics
NPI:1780044529
Name:DIAZ, NICHOLAS ANTHONY (DDS)
Entity type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:ANTHONY
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 1:2936 HYLAN BLVD
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10306-4056
Mailing Address - Country:US
Mailing Address - Phone:718-987-6453
Mailing Address - Fax:
Practice Address - Street 1:2936 HYLAN BLVD
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10306-4056
Practice Address - Country:US
Practice Address - Phone:718-987-6453
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-06
Last Update Date:2025-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22D102623600122300000X
NY0649551223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist