1740490598 NPI number — DIAZ-MANIEGO PROFESSIONAL DENTAL CORPORATION

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1740490598 NPI number — DIAZ-MANIEGO PROFESSIONAL DENTAL CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DIAZ-MANIEGO PROFESSIONAL DENTAL CORPORATION
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
SAN LEANDRO PLAZA DENTAL OFFICE
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1740490598
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
263 DAVIS ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN LEANDRO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94577-2742
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
510-357-8878
Provider Business Mailing Address Fax Number:
510-357-8898

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
263 DAVIS ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAN LEANDRO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94577-2742
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
510-357-8878
Provider Business Practice Location Address Fax Number:
510-357-8898
Provider Enumeration Date:
05/23/2007

Additional Information

Authorized Official

Authorized Official Last Name:
MANIEGO
Authorized Official First Name:
ROGELIA
Authorized Official Middle Name:
CASTRO
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
510-357-8878

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  49144 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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