Provider Demographics
NPI:1255937546
Name:RODRIGUEZ, ANGILEENA MARISSA (HM3)
Entity type:Individual
Prefix:MS
First Name:ANGILEENA
Middle Name:MARISSA
Last Name:RODRIGUEZ
Suffix:
Gender:F
Credentials:HM3
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1ST DENBN ATTN: CREDENTIALS
Mailing Address - Street 2:BOX 555221
Mailing Address - City:CAMP PENDELTON
Mailing Address - State:CA
Mailing Address - Zip Code:92055
Mailing Address - Country:US
Mailing Address - Phone:928-269-7130
Mailing Address - Fax:
Practice Address - Street 1:1175 HART ST
Practice Address - Street 2:
Practice Address - City:YUMA
Practice Address - State:AZ
Practice Address - Zip Code:85369
Practice Address - Country:US
Practice Address - Phone:928-269-7130
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-10
Last Update Date:2020-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist