Provider Demographics
NPI:1760124879
Name:RODRIGUEZ, JENNIFER (DDS)
Entity Type:Individual
Prefix:
First Name:JENNIFER
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 1:1680 PELHAM PKWY S APT 105
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10461-1123
Mailing Address - Country:US
Mailing Address - Phone:646-713-4383
Mailing Address - Fax:
Practice Address - Street 1:595 MADISON AVE FL 27
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10022-1649
Practice Address - Country:US
Practice Address - Phone:212-758-9498
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-09
Last Update Date:2024-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY063578122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program