Provider Demographics
NPI:1558726489
Name:GAMALIEL I. RODRIGUEZ, DDS, PC
Entity Type:Organization
Organization Name:GAMALIEL I. RODRIGUEZ, DDS, PC
Other - Org Name:NORTHERN LIGHTS DENTAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GAMALIEL
Authorized Official - Middle Name:ISSAC
Authorized Official - Last Name:RODRIGUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:907-490-0127
Mailing Address - Street 1:2595 SAINT NICHOLAS DR
Mailing Address - Street 2:
Mailing Address - City:NORTH POLE
Mailing Address - State:AK
Mailing Address - Zip Code:99705-7747
Mailing Address - Country:US
Mailing Address - Phone:907-490-4629
Mailing Address - Fax:907-490-4649
Practice Address - Street 1:2595 SAINT NICHOLAS DR
Practice Address - Street 2:
Practice Address - City:NORTH POLE
Practice Address - State:AK
Practice Address - Zip Code:99705-7747
Practice Address - Country:US
Practice Address - Phone:907-490-4629
Practice Address - Fax:907-490-4649
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-18
Last Update Date:2015-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AKAA8281223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty