Provider Demographics
NPI:1356414411
Name:SHU RODRIGUEZ, YVONNE (DDS)
Entity type:Individual
Prefix:
First Name:YVONNE
Middle Name:
Last Name:SHU RODRIGUEZ
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1640 INDIAN HILL BLVD
Mailing Address - Street 2:
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91767-3728
Mailing Address - Country:US
Mailing Address - Phone:909-482-4500
Mailing Address - Fax:909-482-4502
Practice Address - Street 1:1640 INDIAN HILL BLVD
Practice Address - Street 2:
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91767-3728
Practice Address - Country:US
Practice Address - Phone:909-482-4500
Practice Address - Fax:909-482-4502
Is Sole Proprietor?:No
Enumeration Date:2006-11-16
Last Update Date:2021-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA415471223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA954876236OtherTAX IDENTIFICATION NUMBER
CAG9220601Medicaid
CAD41547Medicaid
CA771913OtherUNITED CONCORDIA PROVIDER
CAB41547OtherHEALTHY FAMILIES PROVIDER