=====================================================
General NPI Number Information
=====================================================
NPI Number | 1801921671
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MIRILIS M RODRIGUEZ DDS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/22/2007
-----------------------------------------------------
Last Update Date | 03/07/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11865 SW 26TH STREET STE G10
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33175
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-222-1150
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1322 SW 154 AVE
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33194
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-227-2424
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTIST
-----------------------------------------------------
Name | MIRILIS M RODRIGUEZ
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 305-222-1150
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | DN16058
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------