Provider Demographics
NPI:1366559775
Name:RODRIGUEZ, PAUL R (DDS)
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:R
Last Name:RODRIGUEZ
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:703 N TEJON ST
Mailing Address - Street 2:SUITE D
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80903-1094
Mailing Address - Country:US
Mailing Address - Phone:719-633-5501
Mailing Address - Fax:719-471-4811
Practice Address - Street 1:703 N TEJON ST
Practice Address - Street 2:SUITE D
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80903-1094
Practice Address - Country:US
Practice Address - Phone:719-633-5501
Practice Address - Fax:719-471-4811
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1056691223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice