Healthcare Provider Details

I. General information

NPI: 1194066217
Provider Name (Legal Business Name): MANUEL RODRIGUEZ
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/14/2013
Last Update Date: 03/14/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

TAJIN 956
CD. JUAREZ CHIHUAHUA
32330
MX

IV. Provider business mailing address

PO BOX 12385
EL PASO TX
79913-0385
US

V. Phone/Fax

Practice location:
  • Phone: 011526562518361
  • Fax:
Mailing address:
  • Phone: 915-726-0929
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number4401320
License Number StateZZ

VIII. Authorized Official

Name: MANUEL RODRIGUEZ
Title or Position: OWNER
Credential: DDS
Phone: 915-726-0929