Healthcare Provider Details

I. General information

NPI: 1083260301
Provider Name (Legal Business Name): CYBILL LISA RODRIGUEZ DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/13/2019
Last Update Date: 09/27/2024
Certification Date: 09/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3501 N HALSTED ST
CHICAGO IL
60657-1832
US

IV. Provider business mailing address

6348 S AUSTIN AVE
CHICAGO IL
60638-5341
US

V. Phone/Fax

Practice location:
  • Phone: 773-388-1600
  • Fax:
Mailing address:
  • Phone: 773-454-2858
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number019.032346
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: