Healthcare Provider Details

I. General information

NPI: 1902265804
Provider Name (Legal Business Name): DOLORES RODRIGUEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/19/2016
Last Update Date: 02/19/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

855 ANTHONY DR
ANTHONY NM
88021-9325
US

IV. Provider business mailing address

855 ANTHONY DR
ANTHONY NM
88021-9325
US

V. Phone/Fax

Practice location:
  • Phone: 575-882-3607
  • Fax:
Mailing address:
  • Phone: 575-882-3607
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberDH1243
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: