Provider Demographics
NPI:1710361498
Name:RODRIGUEZ, JONATHAN MARIUS (DDS)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:MARIUS
Last Name:RODRIGUEZ
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 S PALISADES DR
Mailing Address - Street 2:
Mailing Address - City:SIGNAL MOUNTAIN
Mailing Address - State:TN
Mailing Address - Zip Code:37377-2920
Mailing Address - Country:US
Mailing Address - Phone:209-923-3709
Mailing Address - Fax:
Practice Address - Street 1:3824 RINGGOLD RD
Practice Address - Street 2:
Practice Address - City:EAST RIDGE
Practice Address - State:TN
Practice Address - Zip Code:37412-1640
Practice Address - Country:US
Practice Address - Phone:423-629-6015
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-13
Last Update Date:2023-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA64680122300000X
TN12084122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist