Healthcare Provider Details

I. General information

NPI: 1215390216
Provider Name (Legal Business Name): NOEL RODRIGUEZ DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2016
Last Update Date: 03/29/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

NAVAL BRANCH HEALTH CLINIC NAS JAX BLDG 9 64, BIRMINGHAM AVE.
JACKSONVILLE FL
32214-0001
US

IV. Provider business mailing address

NAVAL BRANCH HEALTH CLINIC NAS JAX P.O. BOX 8 BLDG 964
JACKSONVILLE FL
32214-0001
US

V. Phone/Fax

Practice location:
  • Phone: 904-546-7199
  • Fax:
Mailing address:
  • Phone: 904-546-7199
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number25672
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: