Healthcare Provider Details

I. General information

NPI: 1760305577
Provider Name (Legal Business Name): PRISCILLA RODRIGUEZ LEGASPI
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/30/2026
Last Update Date: 07/30/2026
Certification Date: 07/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

972 N 6TH DR
SAN LUIS AZ
85336-1469
US

IV. Provider business mailing address

PO BOX 4965
SAN LUIS AZ
85349-4965
US

V. Phone/Fax

Practice location:
  • Phone: 928-509-1279
  • Fax: 928-361-2599
Mailing address:
  • Phone: 928-509-1279
  • Fax: 928-361-2599

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number15489715
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: