Provider Demographics
NPI:1104250547
Name:RODRIGUEZ, SEBASTIAN (DDS, MSC)
Entity type:Individual
Prefix:
First Name:SEBASTIAN
Middle Name:
Last Name:RODRIGUEZ
Suffix:
Gender:M
Credentials:DDS, MSC
Other - Prefix:
Other - First Name:SEBASTIAN
Other - Middle Name:
Other - Last Name:RODRIGUEZ-GUERRA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:9830 GATEWAY BLVD N
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79924-4410
Mailing Address - Country:US
Mailing Address - Phone:915-755-7900
Mailing Address - Fax:
Practice Address - Street 1:7878 GATEWAY BLVD E STE 300
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79915-1802
Practice Address - Country:US
Practice Address - Phone:617-763-8642
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-21
Last Update Date:2014-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX293171223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics