Provider Demographics
NPI:1033212626
Name:RODRIGUEZ, IVAN ENRIQUE (DMD)
Entity Type:Individual
Prefix:MR
First Name:IVAN
Middle Name:ENRIQUE
Last Name:RODRIGUEZ
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1610 E HARRISON AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:HARLINGEN
Mailing Address - State:TX
Mailing Address - Zip Code:78550-7309
Mailing Address - Country:US
Mailing Address - Phone:956-412-9500
Mailing Address - Fax:956-412-1146
Practice Address - Street 1:1610 E HARRISON AVE
Practice Address - Street 2:SUITE A
Practice Address - City:HARLINGEN
Practice Address - State:TX
Practice Address - Zip Code:78550-7309
Practice Address - Country:US
Practice Address - Phone:956-412-9500
Practice Address - Fax:956-412-1146
Is Sole Proprietor?:No
Enumeration Date:2006-09-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXTX 18670122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist