Healthcare Provider Details

I. General information

NPI: 1780341677
Provider Name (Legal Business Name): LUIS A RODRIGUEZ
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/26/2021
Last Update Date: 11/26/2021
Certification Date: 11/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

KM 128 MX-TIJ RD
TECATE BAJA CALIFORNIA
21478
MX

IV. Provider business mailing address

4275 EXECUTIVE SQ STE 200
LA JOLLA CA
92037-1476
US

V. Phone/Fax

Practice location:
  • Phone: 619-488-3200
  • Fax: 619-908-1095
Mailing address:
  • Phone: 619-488-3200
  • Fax: 619-908-1095

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. LUIS A RODRIGUEZ
Title or Position: DENTIST
Credential: DDS
Phone: 619-488-3200