Provider Demographics
NPI:1487233664
Name:DIAZ, GABRIELLA DANIELLE (DDS, MSD)
Entity type:Individual
Prefix:
First Name:GABRIELLA
Middle Name:DANIELLE
Last Name:DIAZ
Suffix:
Gender:F
Credentials:DDS, MSD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11215 ANAQUA SPGS
Mailing Address - Street 2:
Mailing Address - City:BOERNE
Mailing Address - State:TX
Mailing Address - Zip Code:78006-8493
Mailing Address - Country:US
Mailing Address - Phone:817-300-6658
Mailing Address - Fax:
Practice Address - Street 1:5419 FREDERICKSBURG RD
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-3503
Practice Address - Country:US
Practice Address - Phone:210-616-0980
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-06
Last Update Date:2022-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX359751223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics