Provider Demographics
NPI:1063516359
Name:RODRIGUEZ, LUIS (DN0012951)
Entity type:Individual
Prefix:DR
First Name:LUIS
Middle Name:
Last Name:RODRIGUEZ
Suffix:
Gender:M
Credentials:DN0012951
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:560 E 49TH ST
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33013-1962
Mailing Address - Country:US
Mailing Address - Phone:305-688-1246
Mailing Address - Fax:305-685-7825
Practice Address - Street 1:560 E 49TH ST
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33013-1962
Practice Address - Country:US
Practice Address - Phone:305-688-1246
Practice Address - Fax:305-685-7825
Is Sole Proprietor?:No
Enumeration Date:2006-09-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN00129511223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL073728300Medicaid