Provider Demographics
NPI:1649202920
Name:RODRIGUEZ, LUIS JACOMINO (DMD, MS)
Entity Type:Individual
Prefix:DR
First Name:LUIS
Middle Name:JACOMINO
Last Name:RODRIGUEZ
Suffix:
Gender:M
Credentials:DMD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4695 W 4TH AVE
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33012-3937
Mailing Address - Country:US
Mailing Address - Phone:305-825-8888
Mailing Address - Fax:305-825-9909
Practice Address - Street 1:4695 W 4TH AVE
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33012-3937
Practice Address - Country:US
Practice Address - Phone:305-825-8888
Practice Address - Fax:305-825-9909
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-07
Last Update Date:2013-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN00138321223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL071356200Medicaid