Healthcare Provider Details

I. General information

NPI: 1821832510
Provider Name (Legal Business Name): NOELVIS RODRIGUEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2024
Last Update Date: 06/19/2024
Certification Date: 06/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

313 N JEFFERSON ST
PERRY FL
32347-2653
US

IV. Provider business mailing address

1894 MERCHANTS ROW BLVD APT 618
TALLAHASSEE FL
32311-8875
US

V. Phone/Fax

Practice location:
  • Phone: 850-584-2674
  • Fax:
Mailing address:
  • Phone: 832-792-7875
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number29100
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: