Provider Demographics
NPI:1427345057
Name:TEJADA, RODOLFO (DDS)
Entity type:Individual
Prefix:
First Name:RODOLFO
Middle Name:
Last Name:TEJADA
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 1:10452 PROVENCE DR
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32836-8873
Mailing Address - Country:US
Mailing Address - Phone:860-919-2104
Mailing Address - Fax:
Practice Address - Street 1:2435 S VOLUSIA AVE STE D2
Practice Address - Street 2:
Practice Address - City:ORANGE CITY
Practice Address - State:FL
Practice Address - Zip Code:32763-7643
Practice Address - Country:US
Practice Address - Phone:386-878-4395
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-04
Last Update Date:2019-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN208261223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL023632900Medicaid