Provider Demographics
NPI:1770814717
Name:RODRIGUEZ, MYLA R (DDS)
Entity Type:Individual
Prefix:DR
First Name:MYLA
Middle Name:R
Last Name:RODRIGUEZ
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:MYLA
Other - Middle Name:R
Other - Last Name:RODRIGUEZ-SANTIAGO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DDS
Mailing Address - Street 1:3323 ALABAMA ST
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91214-1231
Mailing Address - Country:US
Mailing Address - Phone:818-726-1597
Mailing Address - Fax:
Practice Address - Street 1:1321 N VERMONT AVE
Practice Address - Street 2:SUITE 6
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90027-6307
Practice Address - Country:US
Practice Address - Phone:323-662-8354
Practice Address - Fax:323-286-0281
Is Sole Proprietor?:No
Enumeration Date:2010-01-14
Last Update Date:2014-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA58558122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist