Provider Demographics
NPI:1053638585
Name:VILLALUZ AND RODRIGUEZ, PS
Entity Type:Organization
Organization Name:VILLALUZ AND RODRIGUEZ, PS
Other - Org Name:SOUTH VIEW FAMILY DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:P
Authorized Official - Last Name:VILLALUZ
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:360-567-0296
Mailing Address - Street 1:3200 SE 164TH AVE STE 207
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98683-1109
Mailing Address - Country:US
Mailing Address - Phone:360-567-0296
Mailing Address - Fax:360-567-0299
Practice Address - Street 1:3200 SE 164TH AVE STE 207
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98683-1109
Practice Address - Country:US
Practice Address - Phone:360-567-0296
Practice Address - Fax:360-567-0299
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-23
Last Update Date:2010-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE000082041223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5051651Medicaid