Provider Demographics
NPI:1518686427
Name:RODRIGUEZ, PETER
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:
Last Name:RODRIGUEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1341 LAWRENCE RD
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:TX
Mailing Address - Zip Code:77630-8129
Mailing Address - Country:US
Mailing Address - Phone:909-749-1483
Mailing Address - Fax:
Practice Address - Street 1:3109 EDGAR BROWN DR STE H
Practice Address - Street 2:
Practice Address - City:WEST ORANGE
Practice Address - State:TX
Practice Address - Zip Code:77630-5381
Practice Address - Country:US
Practice Address - Phone:409-330-4252
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-24
Last Update Date:2022-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX389541223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice