Provider Demographics
NPI:1437299021
Name:PICAZO, RODOLFO HERNANDEZ (DDS)
Entity Type:Individual
Prefix:
First Name:RODOLFO
Middle Name:HERNANDEZ
Last Name:PICAZO
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1436 HIGHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:NATIONAL CITY
Mailing Address - State:CA
Mailing Address - Zip Code:91950-4624
Mailing Address - Country:US
Mailing Address - Phone:619-474-7417
Mailing Address - Fax:619-474-4540
Practice Address - Street 1:1436 HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:NATIONAL CITY
Practice Address - State:CA
Practice Address - Zip Code:91950-4624
Practice Address - Country:US
Practice Address - Phone:619-474-7417
Practice Address - Fax:619-474-4540
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA27186122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered122300000XDental ProvidersDentist
Not Answered1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAB27186-01OtherDENTICAL