Healthcare Provider Details

I. General information

NPI: 1659723898
Provider Name (Legal Business Name): JOSEPH RODRIGUEZ DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2016
Last Update Date: 05/29/2026
Certification Date: 05/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5004 CAROLINA FOREST BLVD
MYRTLE BEACH SC
29579-3579
US

IV. Provider business mailing address

5004 CAROLINA FOREST BLVD
MYRTLE BEACH SC
29579-3579
US

V. Phone/Fax

Practice location:
  • Phone: 843-380-9080
  • Fax: 843-380-9081
Mailing address:
  • Phone: 843-380-9080
  • Fax: 843-380-9081

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDGD11379
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN22083
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberDGD11381
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: