Provider Demographics
NPI:1922276765
Name:THOMAS L RODERICK DDS
Entity Type:Organization
Organization Name:THOMAS L RODERICK DDS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:L
Authorized Official - Last Name:RODERICK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:619-574-1810
Mailing Address - Street 1:2333 CAMINO DEL RIO S
Mailing Address - Street 2:SUITE 140
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92108-4135
Mailing Address - Country:US
Mailing Address - Phone:619-574-1810
Mailing Address - Fax:619-574-1326
Practice Address - Street 1:2333 CAMINO DEL RIO SOUTH
Practice Address - Street 2:#140
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-4135
Practice Address - Country:US
Practice Address - Phone:619-574-1810
Practice Address - Fax:619-574-1326
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:THOMAS L RODERICK
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-02-14
Last Update Date:2008-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA336551223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty