Provider Demographics
NPI:1962971200
Name:RODRIGUEZ, IVELISS (DMD)
Entity type:Individual
Prefix:
First Name:IVELISS
Middle Name:
Last Name:RODRIGUEZ
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1830 SABAL PALM DR APT 405
Mailing Address - Street 2:
Mailing Address - City:DAVIE
Mailing Address - State:FL
Mailing Address - Zip Code:33324-5938
Mailing Address - Country:US
Mailing Address - Phone:786-357-6000
Mailing Address - Fax:
Practice Address - Street 1:12801 W SUNRISE BLVD # F222
Practice Address - Street 2:
Practice Address - City:SUNRISE
Practice Address - State:FL
Practice Address - Zip Code:33323-4020
Practice Address - Country:US
Practice Address - Phone:954-846-7171
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-15
Last Update Date:2020-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN23099122300000X, 1223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics
No122300000XDental ProvidersDentist