Provider Demographics
NPI:1336806868
Name:RODRIGUEZ, YNDIRA STACEY
Entity Type:Individual
Prefix:
First Name:YNDIRA
Middle Name:STACEY
Last Name:RODRIGUEZ
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 1:442 W 160TH ST APT 1D
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10032-6340
Mailing Address - Country:US
Mailing Address - Phone:646-643-5664
Mailing Address - Fax:
Practice Address - Street 1:36101 GOODWIN DR
Practice Address - Street 2:
Practice Address - City:LOCUST GROVE
Practice Address - State:VA
Practice Address - Zip Code:22508-2029
Practice Address - Country:US
Practice Address - Phone:560-680-0923
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-18
Last Update Date:2021-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401417714122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist