Provider Demographics
NPI:1902265804
Name:RODRIGUEZ, DOLORES
Entity Type:Individual
Prefix:
First Name:DOLORES
Middle Name:
Last Name:RODRIGUEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:855 ANTHONY DR
Mailing Address - Street 2:
Mailing Address - City:ANTHONY
Mailing Address - State:NM
Mailing Address - Zip Code:88021-9325
Mailing Address - Country:US
Mailing Address - Phone:575-882-3607
Mailing Address - Fax:
Practice Address - Street 1:855 ANTHONY DR
Practice Address - Street 2:
Practice Address - City:ANTHONY
Practice Address - State:NM
Practice Address - Zip Code:88021-9325
Practice Address - Country:US
Practice Address - Phone:575-882-3607
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-19
Last Update Date:2016-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDH1243124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist