Provider Demographics
NPI:1801405105
Name:RODRIGUEZ OLIVA, GUSTAVO E (DMD)
Entity Type:Individual
Prefix:
First Name:GUSTAVO
Middle Name:E
Last Name:RODRIGUEZ OLIVA
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 1:600 TECHNOLOGY PARK STE 101
Mailing Address - Street 2:
Mailing Address - City:LAKE MARY
Mailing Address - State:FL
Mailing Address - Zip Code:32746-7122
Mailing Address - Country:US
Mailing Address - Phone:407-543-8509
Mailing Address - Fax:
Practice Address - Street 1:3122 53RD AVE E
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34203-4311
Practice Address - Country:US
Practice Address - Phone:941-357-2968
Practice Address - Fax:941-216-0029
Is Sole Proprietor?:No
Enumeration Date:2020-07-23
Last Update Date:2020-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN252551223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice