=====================================================
General NPI Number Information
=====================================================
NPI Number | 1982201505
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ASHLEY RODRIGUEZ DMD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/06/2020
-----------------------------------------------------
Last Update Date | 10/06/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2208 N MANNHEIM RD
-----------------------------------------------------
City | MELROSE PARK
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60164-1837
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-451-7777
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2208 N MANNHEIM RD
-----------------------------------------------------
City | MELROSE PARK
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60164-1837
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-451-7777
-----------------------------------------------------
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 | 019032904
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 019032904
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------