Provider Demographics
NPI:1093311250
Name:RODRIGUEZ SOLIS, MAX EMILIANO (HN)
Entity Type:Individual
Prefix:
First Name:MAX
Middle Name:EMILIANO
Last Name:RODRIGUEZ SOLIS
Suffix:
Gender:M
Credentials:HN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1ST DNBN ATTN: CREDENTIALS
Mailing Address - Street 2:BOX 555221
Mailing Address - City:CAMP PENDELTON
Mailing Address - State:CA
Mailing Address - Zip Code:92055
Mailing Address - Country:US
Mailing Address - Phone:469-810-9157
Mailing Address - Fax:
Practice Address - Street 1:1175 HART ST
Practice Address - Street 2:
Practice Address - City:YUMA
Practice Address - State:AZ
Practice Address - Zip Code:85369
Practice Address - Country:US
Practice Address - Phone:469-810-9157
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-11
Last Update Date:2020-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist