Provider Demographics
NPI:1538325964
Name:RODRIGUEZ, AMARILYS (DMD)
Entity Type:Individual
Prefix:
First Name:AMARILYS
Middle Name:
Last Name:RODRIGUEZ
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1841 S CALUMET AVE APT 1111
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60616-4812
Mailing Address - Country:US
Mailing Address - Phone:617-755-1889
Mailing Address - Fax:
Practice Address - Street 1:1841 S CALUMET AVE APT 1111
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60616-4812
Practice Address - Country:US
Practice Address - Phone:617-755-1889
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-05
Last Update Date:2009-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL021.0022921223E0200X
IL019.026975122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics
No122300000XDental ProvidersDentist