Provider Demographics
NPI:1790879229
Name:RODRIGUEZ, RAFAELINA
Entity Type:Individual
Prefix:
First Name:RAFAELINA
Middle Name:
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 1:304 WEST 109TH. ST.
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10025-2175
Mailing Address - Country:US
Mailing Address - Phone:212-663-4300
Mailing Address - Fax:212-866-0865
Practice Address - Street 1:304 WEST 109TH. ST.
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10025-2175
Practice Address - Country:US
Practice Address - Phone:212-663-4300
Practice Address - Fax:212-866-0865
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2016-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY038019-11223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00841149Medicaid