Healthcare Provider Details

I. General information

NPI: 1982201505
Provider Name (Legal Business Name): ASHLEY RODRIGUEZ DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/06/2020
Last Update Date: 10/06/2020
Certification Date: 09/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2208 N MANNHEIM RD
MELROSE PARK IL
60164-1837
US

IV. Provider business mailing address

2208 N MANNHEIM RD
MELROSE PARK IL
60164-1837
US

V. Phone/Fax

Practice location:
  • Phone: 847-451-7777
  • Fax:
Mailing address:
  • Phone: 847-451-7777
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number019032904
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number019032904
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: