Healthcare Provider Details

I. General information

NPI: 1760632210
Provider Name (Legal Business Name): LUIS MANUEL RODRIGUEZ DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/21/2008
Last Update Date: 06/20/2025
Certification Date: 06/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CALLE 4TA DIAZ MIRON 8150 - 205 ZONA CENTRO
TIJUANA BC
22000
MX

IV. Provider business mailing address

3530 BEYER BLVD APT 102
SAN YSIDRO CA
92173-1353
US

V. Phone/Fax

Practice location:
  • Phone: 877-839-2248
  • Fax: 877-839-2248
Mailing address:
  • Phone: 877-838-2248
  • Fax: 877-839-2248

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number1324319
License Number StateZZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: