Provider Demographics
NPI:1063054385
Name:SANTIAGO RODRIGUEZ, GABRIELA NICOLLE (DMD)
Entity type:Individual
Prefix:
First Name:GABRIELA
Middle Name:NICOLLE
Last Name:SANTIAGO RODRIGUEZ
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1032
Mailing Address - Street 2:
Mailing Address - City:VEGA ALTA
Mailing Address - State:PR
Mailing Address - Zip Code:00692-1032
Mailing Address - Country:US
Mailing Address - Phone:787-412-2959
Mailing Address - Fax:
Practice Address - Street 1:686 ST, VILLA REAL
Practice Address - Street 2:1 A-1
Practice Address - City:VEGA BAJA
Practice Address - State:PR
Practice Address - Zip Code:00693
Practice Address - Country:US
Practice Address - Phone:787-858-5155
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-09
Last Update Date:2019-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR3334122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist