Provider Demographics
NPI:1942945720
Name:RODRIGUEZ LICEA, ALEJANDRA CAROLINA
Entity Type:Individual
Prefix:
First Name:ALEJANDRA
Middle Name:CAROLINA
Last Name:RODRIGUEZ LICEA
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 1:3640 TUSCANY PL
Mailing Address - Street 2:
Mailing Address - City:TURLOCK
Mailing Address - State:CA
Mailing Address - Zip Code:95382-0362
Mailing Address - Country:US
Mailing Address - Phone:702-576-6038
Mailing Address - Fax:
Practice Address - Street 1:706 MAIN ST
Practice Address - Street 2:
Practice Address - City:LIVINGSTON
Practice Address - State:CA
Practice Address - Zip Code:95334-1308
Practice Address - Country:US
Practice Address - Phone:209-535-9933
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-05
Last Update Date:2022-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1073851223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice