Provider Demographics
NPI:1043481765
Name:MARTHA E. DIAZ D.D.S., P.C.
Entity type:Organization
Organization Name:MARTHA E. DIAZ D.D.S., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:EUGENIO
Authorized Official - Middle Name:
Authorized Official - Last Name:SIERRA
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:847-599-3855
Mailing Address - Street 1:2634 GRAND AVE
Mailing Address - Street 2:SUITE 207
Mailing Address - City:WAUKEGAN
Mailing Address - State:IL
Mailing Address - Zip Code:60085-2458
Mailing Address - Country:US
Mailing Address - Phone:847-599-3855
Mailing Address - Fax:847-599-3859
Practice Address - Street 1:2634 GRAND AVE
Practice Address - Street 2:SUITE 207
Practice Address - City:WAUKEGAN
Practice Address - State:IL
Practice Address - Zip Code:60085-2458
Practice Address - Country:US
Practice Address - Phone:847-599-3855
Practice Address - Fax:847-599-3859
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-20
Last Update Date:2008-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization