Provider Demographics
NPI:1265646129
Name:RODRIGUEZ, MAIRA (DDS)
Entity Type:Individual
Prefix:DR
First Name:MAIRA
Middle Name:
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 1:1888 PRAIRIE DUNES CT S
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48108-8641
Mailing Address - Country:US
Mailing Address - Phone:734-255-1839
Mailing Address - Fax:734-947-3633
Practice Address - Street 1:24929 GODDARD RD
Practice Address - Street 2:
Practice Address - City:TAYLOR
Practice Address - State:MI
Practice Address - Zip Code:48180-3930
Practice Address - Country:US
Practice Address - Phone:734-947-3621
Practice Address - Fax:734-947-3633
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010181891223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice