Provider Demographics
NPI:1720533185
Name:RODRIGUEZ, ANGEL (DDS)
Entity Type:Individual
Prefix:DR
First Name:ANGEL
Middle Name:
Last Name:RODRIGUEZ
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8012 COLFAX LN
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76134-5314
Mailing Address - Country:US
Mailing Address - Phone:817-914-2766
Mailing Address - Fax:
Practice Address - Street 1:3806 E BROAD ST STE 108
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:TX
Practice Address - Zip Code:76063-5621
Practice Address - Country:US
Practice Address - Phone:817-842-2600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-15
Last Update Date:2016-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX32222122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist