Provider Demographics
NPI:1790768075
Name:RODRIGUEZ, FERMIN HERIBERTO (DMD)
Entity Type:Individual
Prefix:
First Name:FERMIN
Middle Name:HERIBERTO
Last Name:RODRIGUEZ
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1160
Mailing Address - Street 2:
Mailing Address - City:YABUCOA
Mailing Address - State:PR
Mailing Address - Zip Code:00767-1160
Mailing Address - Country:US
Mailing Address - Phone:787-893-0410
Mailing Address - Fax:
Practice Address - Street 1:108 LUIS MUNOZ RIVERA ST
Practice Address - Street 2:
Practice Address - City:YABUCOA
Practice Address - State:PR
Practice Address - Zip Code:00767-1160
Practice Address - Country:US
Practice Address - Phone:787-893-0410
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR15051223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR042095OtherLA CRUZ AZUL DE PR
PR7670050OtherHUMANA INSURANCE