Healthcare Provider Details

I. General information

NPI: 1962971200
Provider Name (Legal Business Name): IVELISS RODRIGUEZ DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/15/2018
Last Update Date: 07/07/2020
Certification Date: 07/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12801 W SUNRISE BLVD # F222
SUNRISE FL
33323-4020
US

IV. Provider business mailing address

1830 SABAL PALM DR APT 405
DAVIE FL
33324-5938
US

V. Phone/Fax

Practice location:
  • Phone: 954-846-7171
  • Fax:
Mailing address:
  • Phone: 786-357-6000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN23099
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License NumberDN23099
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: