Healthcare Provider Details

I. General information

NPI: 1437179314
Provider Name (Legal Business Name): RUBEN RODRIGUEZ JR. D.D.S
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

630 E BRAVO BLVD SUITE 1
ROMA TX
78584-5720
US

IV. Provider business mailing address

PO BOX 769
MISSION TX
78573-0013
US

V. Phone/Fax

Practice location:
  • Phone: 956-849-7050
  • Fax: 956-849-1435
Mailing address:
  • Phone: 956-849-7050
  • Fax: 956-849-1435

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number17298
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: