Provider Demographics
NPI:1770912651
Name:IVAN RODRIGUEZ, DDS INC
Entity type:Organization
Organization Name:IVAN RODRIGUEZ, DDS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:VICKY
Authorized Official - Middle Name:LOURDES
Authorized Official - Last Name:FLORES
Authorized Official - Suffix:
Authorized Official - Credentials:RDA
Authorized Official - Phone:415-642-6777
Mailing Address - Street 1:2460 MISSION ST, SUITE 222
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94110
Mailing Address - Country:US
Mailing Address - Phone:415-642-6777
Mailing Address - Fax:415-642-6778
Practice Address - Street 1:2460 MISSION ST, SUITE 222
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94110
Practice Address - Country:US
Practice Address - Phone:415-642-6777
Practice Address - Fax:415-642-6778
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-01
Last Update Date:2013-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA42219122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty