Provider Demographics
NPI:1619708526
Name:RODRIGUEZ, JUAN ANTONIO JR
Entity type:Individual
Prefix:
First Name:JUAN
Middle Name:ANTONIO
Last Name:RODRIGUEZ
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:BLDG 25501 BRAINARD AVE
Mailing Address - Street 2:
Mailing Address - City:FT EISENHOWER
Mailing Address - State:GA
Mailing Address - Zip Code:30905
Mailing Address - Country:US
Mailing Address - Phone:706-787-7050
Mailing Address - Fax:
Practice Address - Street 1:BLDG 25501 BRAINARD AVE
Practice Address - Street 2:
Practice Address - City:FT EISENHOWER
Practice Address - State:GA
Practice Address - Zip Code:30905
Practice Address - Country:US
Practice Address - Phone:706-787-7050
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-12
Last Update Date:2024-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist