Provider Demographics
NPI:1629811096
Name:RODRIGUEZ, BRYANT
Entity type:Individual
Prefix:DR
First Name:BRYANT
Middle Name:
Last Name:RODRIGUEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 N PARKSIDE AVE APT 2D
Mailing Address - Street 2:
Mailing Address - City:GLEN ELLYN
Mailing Address - State:IL
Mailing Address - Zip Code:60137-5759
Mailing Address - Country:US
Mailing Address - Phone:954-235-7562
Mailing Address - Fax:
Practice Address - Street 1:7106 CERMAK RD
Practice Address - Street 2:
Practice Address - City:BERWYN
Practice Address - State:IL
Practice Address - Zip Code:60402
Practice Address - Country:US
Practice Address - Phone:708-540-1000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-14
Last Update Date:2024-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.035086122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist