Provider Demographics
NPI:1366158792
Name:IBARRIA, RODOLFO
Entity type:Individual
Prefix:
First Name:RODOLFO
Middle Name:
Last Name:IBARRIA
Suffix:
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 1:4076 CATTLEMEN RD
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34233-5033
Mailing Address - Country:US
Mailing Address - Phone:786-372-5094
Mailing Address - Fax:
Practice Address - Street 1:4076 CATTLEMEN RD
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34233-5033
Practice Address - Country:US
Practice Address - Phone:786-372-5094
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-30
Last Update Date:2025-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QS1000X
MADN18598111223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No261QS1000XAmbulatory Health Care FacilitiesClinic/CenterStudent Health