Healthcare Provider Details

I. General information

NPI: 1154737377
Provider Name (Legal Business Name): PAOLA CAROLINA RODRIGUEZ D.M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/08/2014
Last Update Date: 08/16/2023
Certification Date: 08/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

109 WHITEHALL DR STE 118
ST AUGUSTINE FL
32086-5266
US

IV. Provider business mailing address

109 WHITEHALL DR STE 118
ST AUGUSTINE FL
32086-5266
US

V. Phone/Fax

Practice location:
  • Phone: 904-824-0990
  • Fax:
Mailing address:
  • Phone: 904-824-0990
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN24700
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: