Provider Demographics
NPI:1386752574
Name:RODERICK, THOMAS L (DDS)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:L
Last Name:RODERICK
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 1:2333 CAMINO DEL RIO S
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92108-3607
Mailing Address - Country:US
Mailing Address - Phone:619-574-1810
Mailing Address - Fax:619-574-1326
Practice Address - Street 1:1166 K ST
Practice Address - Street 2:
Practice Address - City:BRAWLEY
Practice Address - State:CA
Practice Address - Zip Code:92227-2737
Practice Address - Country:US
Practice Address - Phone:760-344-3583
Practice Address - Fax:760-344-8480
Is Sole Proprietor?:No
Enumeration Date:2006-08-28
Last Update Date:2016-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA336551223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice