Provider Demographics
NPI:1831150168
Name:RODRIGUEZ, IVETTE J (DMD)
Entity type:Individual
Prefix:DR
First Name:IVETTE
Middle Name:J
Last Name:RODRIGUEZ
Suffix:
Gender:F
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:PO BOX 9190
Mailing Address - Street 2:
Mailing Address - City:HUMACAO
Mailing Address - State:PR
Mailing Address - Zip Code:00792
Mailing Address - Country:US
Mailing Address - Phone:787-852-6729
Mailing Address - Fax:787-789-1025
Practice Address - Street 1:AVE PADRE RIVERA 10
Practice Address - Street 2:
Practice Address - City:HUMACAO
Practice Address - State:PR
Practice Address - Zip Code:00791
Practice Address - Country:US
Practice Address - Phone:787-852-6729
Practice Address - Fax:787-852-3000
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-28
Last Update Date:2014-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR9341223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
42097OtherSSS