Provider Demographics
NPI:1447486618
Name:RODRIGUEZ, AMY KATHERINE (DDS)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:KATHERINE
Last Name:RODRIGUEZ
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4420 PRAIRIE AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60513-2502
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:719 LAKE ST
Practice Address - Street 2:
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60301-1406
Practice Address - Country:US
Practice Address - Phone:708-386-3200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-02
Last Update Date:2014-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.027947122300000X
KS60722122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist