Provider Demographics
NPI:1083260301
Name:RODRIGUEZ, CYBILL LISA (DMD)
Entity Type:Individual
Prefix:MS
First Name:CYBILL
Middle Name:LISA
Last Name:RODRIGUEZ
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6348 S AUSTIN AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60638-5341
Mailing Address - Country:US
Mailing Address - Phone:773-454-2858
Mailing Address - Fax:
Practice Address - Street 1:6737 W ARCHER AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60638-2332
Practice Address - Country:US
Practice Address - Phone:773-586-5767
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-13
Last Update Date:2020-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.032346122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist