Provider Demographics
NPI:1790257806
Name:RODRIGUEZ, JASMIN MARIE
Entity Type:Individual
Prefix:
First Name:JASMIN
Middle Name:MARIE
Last Name:RODRIGUEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2429 CHENANGO RD
Mailing Address - Street 2:
Mailing Address - City:UTICA
Mailing Address - State:NY
Mailing Address - Zip Code:13502-5908
Mailing Address - Country:US
Mailing Address - Phone:315-793-7620
Mailing Address - Fax:
Practice Address - Street 1:1651 ONEIDA ST
Practice Address - Street 2:
Practice Address - City:UTICA
Practice Address - State:NY
Practice Address - Zip Code:13501-4866
Practice Address - Country:US
Practice Address - Phone:315-793-7600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-31
Last Update Date:2018-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY029566124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist