=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336806868
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | YNDIRA STACEY RODRIGUEZ
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/18/2021
-----------------------------------------------------
Last Update Date | 11/18/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 36101 GOODWIN DR
-----------------------------------------------------
City | LOCUST GROVE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22508-2029
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 560-680-0923
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 442 W 160TH ST APT 1D
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10032-6340
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 646-643-5664
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 0401417714
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------