Provider Demographics
NPI:1124758800
Name:RODRIGUEZ, DESTINI FAITH (DDS)
Entity type:Individual
Prefix:
First Name:DESTINI
Middle Name:FAITH
Last Name:RODRIGUEZ
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:631 MEADOWBROOKE PL
Mailing Address - Street 2:
Mailing Address - City:DUNCANVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75137-3821
Mailing Address - Country:US
Mailing Address - Phone:214-543-9577
Mailing Address - Fax:
Practice Address - Street 1:7355 N BEACH ST STE 133
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76137-1898
Practice Address - Country:US
Practice Address - Phone:817-935-8686
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-14
Last Update Date:2022-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX386021223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty