Provider Demographics
NPI:1992080428
Name:FUENTEALBA HIDALGO, RODRIGO (DDS)
Entity type:Individual
Prefix:
First Name:RODRIGO
Middle Name:
Last Name:FUENTEALBA HIDALGO
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 1:800 ROSE ST RM D642
Mailing Address - Street 2:UNIVERSITY OF KENTUCKY COLLEGE OF DENTISTRY
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40536-0297
Mailing Address - Country:US
Mailing Address - Phone:859-323-5831
Mailing Address - Fax:
Practice Address - Street 1:800 ROSE ST RM D642
Practice Address - Street 2:UNIVERSITY OF KENTUCKY COLLEGE OF DENTISTRY
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40536-0297
Practice Address - Country:US
Practice Address - Phone:859-323-5831
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-16
Last Update Date:2015-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY91311223G0001X, 122300000X, 1223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics
No1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100196940Medicaid