Healthcare Provider Details

I. General information

NPI: 1194155572
Provider Name (Legal Business Name): SAUL RODRIGUEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/20/2013
Last Update Date: 11/20/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

510 GRISWOLD ST
GLENDALE CA
91205
US

IV. Provider business mailing address

510 GRISWOLD ST
GLENDALE CA
91205
US

V. Phone/Fax

Practice location:
  • Phone: 562-347-9109
  • Fax:
Mailing address:
  • Phone: 562-347-9109
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code126800000X
TaxonomyDental Assistant
License Number53502
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: