Provider Demographics
NPI:1982198990
Name:RODRIGUEZ, LUZ MARIAMNE (DMD)
Entity Type:Individual
Prefix:
First Name:LUZ
Middle Name:MARIAMNE
Last Name:RODRIGUEZ
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2985 KALEY DR NW
Mailing Address - Street 2:
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30152-2678
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12460 CRABAPPLE RD STE 801
Practice Address - Street 2:
Practice Address - City:ALPHARETTA
Practice Address - State:GA
Practice Address - Zip Code:30004-6391
Practice Address - Country:US
Practice Address - Phone:770-360-9131
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-22
Last Update Date:2018-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0156981223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice