=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023198397
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LUIS RODRIGUEZ D.D.S.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/17/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11 N ROYAL POINCIANA BLVD SUITE #200
-----------------------------------------------------
City | MIAMI SPRINGS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33166-4423
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-884-2751
-----------------------------------------------------
Fax | 305-884-6119
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1874 SW 138TH AVE
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33175-7500
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-553-4779
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | DN12054
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------