Provider Demographics
NPI:1811911977
Name:URIBE, RODRIGO LORENZO (DMD)
Entity type:Individual
Prefix:DR
First Name:RODRIGO
Middle Name:LORENZO
Last Name:URIBE
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:613 EAST GRADY STREET
Mailing Address - Street 2:P.O.BOX 1408
Mailing Address - City:STATESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30459-1408
Mailing Address - Country:US
Mailing Address - Phone:912-764-5435
Mailing Address - Fax:912-764-9789
Practice Address - Street 1:613 E GRADY ST
Practice Address - Street 2:
Practice Address - City:STATESBORO
Practice Address - State:GA
Practice Address - Zip Code:30458-5104
Practice Address - Country:US
Practice Address - Phone:912-764-5435
Practice Address - Fax:912-764-9789
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2018-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN011060174400000X, 1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000514489AMedicaid
GA85BBBBCMedicare ID - Type Unspecified