Provider Demographics
NPI:1326338179
Name:RODRIGUEZ-ELICEA, MIREYA (RDHAP)
Entity Type:Individual
Prefix:MRS
First Name:MIREYA
Middle Name:
Last Name:RODRIGUEZ-ELICEA
Suffix:
Gender:F
Credentials:RDHAP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17995 LACEBARK CT
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92407-0531
Mailing Address - Country:US
Mailing Address - Phone:909-374-2493
Mailing Address - Fax:
Practice Address - Street 1:10950 CHURCH ST APT 3416
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-8095
Practice Address - Country:US
Practice Address - Phone:909-374-2493
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-13
Last Update Date:2016-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA342124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist