Healthcare Provider Details

I. General information

NPI: 1922210665
Provider Name (Legal Business Name): RODNEY D IDA DDS APC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/04/2007
Last Update Date: 11/08/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17542 IRVINE BLVD STE A
TUSTIN CA
92780-3155
US

IV. Provider business mailing address

17542 IRVINE BLVD SUITE A
TUSTIN CA
92780-3155
US

V. Phone/Fax

Practice location:
  • Phone: 714-547-8494
  • Fax: 714-547-3448
Mailing address:
  • Phone: 714-547-8494
  • Fax: 714-547-3448

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number36250
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License NumberCA36250
License Number StateCA

VIII. Authorized Official

Name: DR. RODNEY DEAN IDA
Title or Position: PRESIDENT
Credential: DDS
Phone: 714-547-8494