Healthcare Provider Details

I. General information

NPI: 1265929640
Provider Name (Legal Business Name): DANIEL RODRIGUEZ DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/20/2018
Last Update Date: 09/12/2020
Certification Date: 09/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

660 S 200 E STE 250
SALT LAKE CITY UT
84111-3846
US

IV. Provider business mailing address

10911 S 1055 W
SOUTH JORDAN UT
84095-8214
US

V. Phone/Fax

Practice location:
  • Phone: 801-359-2256
  • Fax:
Mailing address:
  • Phone: 702-884-1493
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number6159362-9922
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License Number6159362-9922
License Number StateUT
# 3
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number6159362-9922
License Number StateUT
# 4
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: