Provider Demographics
NPI:1700577970
Name:DIKUBA, RODRIGUE (DDS)
Entity Type:Individual
Prefix:DR
First Name:RODRIGUE
Middle Name:
Last Name:DIKUBA
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:DR
Other - First Name:RODRIGUE
Other - Middle Name:
Other - Last Name:DIKUBA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:PO BOX 4793
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87502-4793
Mailing Address - Country:US
Mailing Address - Phone:505-920-8275
Mailing Address - Fax:
Practice Address - Street 1:5505 CENTRAL AVE NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87108-1601
Practice Address - Country:US
Practice Address - Phone:505-920-8275
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-17
Last Update Date:2023-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NMDB-2023-00941223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program