Provider Demographics
NPI:1245960962
Name:RODELA-RODRIGUEZ, FAUSTO (RDH)
Entity type:Individual
Prefix:
First Name:FAUSTO
Middle Name:
Last Name:RODELA-RODRIGUEZ
Suffix:
Gender:M
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1415 TOWN SQUARE LN
Mailing Address - Street 2:
Mailing Address - City:FARIBAULT
Mailing Address - State:MN
Mailing Address - Zip Code:55021-6088
Mailing Address - Country:US
Mailing Address - Phone:507-323-8100
Mailing Address - Fax:833-974-2090
Practice Address - Street 1:1415 TOWN SQUARE LN
Practice Address - Street 2:
Practice Address - City:FARIBAULT
Practice Address - State:MN
Practice Address - Zip Code:55021-6088
Practice Address - Country:US
Practice Address - Phone:507-323-8100
Practice Address - Fax:833-974-2090
Is Sole Proprietor?:No
Enumeration Date:2022-06-15
Last Update Date:2022-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNH11333OtherRDH LICENSE