MEDICARE: MR. ANGEL RODRIGUEZTAPIA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	126800000X	Dental Assistant

General Provider Information

NPI Number	:	1003362559
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. ANGEL RODRIGUEZTAPIA

Provider Business Mailing Address
First Line	:	398 192ND ARMOR TANK BATTALION RD
Second Line	:	USA DENTAC HQS BLDG 1022
City	:	FORT KNOX
State	:	KY
Zip	:	40121-5116
Country	:	US
Telephone Number	:	502-624-6158
Fax Number	:	502-624-2966

Provider Business Practice Location Address
First Line	:	962 1ST INFANTRY DIVISION RD
Second Line	:	JORDAN DENTAL CLINIC BLDG 2724
City	:	FORT KNOX
State	:	KY
Zip	:	40121-5210
Country	:	US
Telephone Number	:	502-626-8301
Fax Number	:	502-626-8300

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/25/2016
Last Update Date	:	08/25/2016

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