Provider Demographics
NPI:1962577254
Name:RODRIGUEZ, J. DOUGLAS (DDS)
Entity type:Individual
Prefix:DR
First Name:J.
Middle Name:DOUGLAS
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 1:1723 E LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:SUNNYSIDE
Mailing Address - State:WA
Mailing Address - Zip Code:98944-2478
Mailing Address - Country:US
Mailing Address - Phone:509-837-4022
Mailing Address - Fax:509-839-4022
Practice Address - Street 1:1723 E LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:SUNNYSIDE
Practice Address - State:WA
Practice Address - Zip Code:98944-2478
Practice Address - Country:US
Practice Address - Phone:509-837-4022
Practice Address - Fax:509-839-4022
Is Sole Proprietor?:No
Enumeration Date:2006-11-21
Last Update Date:2013-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE00007707122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5023783Medicaid