Provider Demographics
NPI:1760632210
Name:RODRIGUEZ, LUIS MANUEL (DDS)
Entity Type:Individual
Prefix:DR
First Name:LUIS
Middle Name:MANUEL
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 1:200 E PARK AVE APT 4
Mailing Address - Street 2:
Mailing Address - City:SAN YSIDRO
Mailing Address - State:CA
Mailing Address - Zip Code:92173-2641
Mailing Address - Country:US
Mailing Address - Phone:877-838-2248
Mailing Address - Fax:877-839-2248
Practice Address - Street 1:CALLE 4TA DIAZ MIRON 8084
Practice Address - Street 2:ZONA CENTRO
Practice Address - City:TIJUANA
Practice Address - State:BC
Practice Address - Zip Code:22000
Practice Address - Country:MX
Practice Address - Phone:877-839-2248
Practice Address - Fax:877-839-2248
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-21
Last Update Date:2008-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ZZ1324319122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist