Provider Demographics
NPI:1588188098
Name:RODRIGUEZ, KAILEEN (DDS)
Entity Type:Individual
Prefix:
First Name:KAILEEN
Middle Name:
Last Name:RODRIGUEZ
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 SHADOW LN # MS 7442
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89106-4124
Mailing Address - Country:US
Mailing Address - Phone:702-774-2698
Mailing Address - Fax:702-774-2696
Practice Address - Street 1:1001 SHADOW LN # MS 7442
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89106-4124
Practice Address - Country:US
Practice Address - Phone:702-774-2698
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-27
Last Update Date:2021-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101704122300000X
NVLL-549-211223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAVAD0000Medicaid