Healthcare Provider Details

I. General information

NPI: 1104119924
Provider Name (Legal Business Name): JOSE RODRIGUEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/26/2011
Last Update Date: 05/26/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3380 LA SIERRA AVE SUITE 108
RIVERSIDE CA
92503-5271
US

IV. Provider business mailing address

3981 CARRICK ST
RIVERSIDE CA
92505-3003
US

V. Phone/Fax

Practice location:
  • Phone: 951-251-8473
  • Fax:
Mailing address:
  • Phone: 951-251-8473
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: