Provider Demographics
NPI:1114389103
Name:RODRIGUEZ, PAOLA
Entity Type:Individual
Prefix:
First Name:PAOLA
Middle Name:
Last Name:RODRIGUEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:PAOLA
Other - Middle Name:ANDREA
Other - Last Name:RODRIGUEZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:17 S WARREN ST
Mailing Address - Street 2:
Mailing Address - City:DOVER
Mailing Address - State:NJ
Mailing Address - Zip Code:07801-4506
Mailing Address - Country:US
Mailing Address - Phone:973-288-5843
Mailing Address - Fax:
Practice Address - Street 1:17 S WARREN ST
Practice Address - Street 2:
Practice Address - City:DOVER
Practice Address - State:NJ
Practice Address - Zip Code:07801-4506
Practice Address - Country:US
Practice Address - Phone:973-288-5843
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-28
Last Update Date:2017-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NJ22DI026528001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program