Provider Demographics
NPI:1629244272
Name:MAIRA M RODRIGUEZ DMD PC
Entity Type:Organization
Organization Name:MAIRA M RODRIGUEZ DMD PC
Other - Org Name:BROAD STREET DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MAIRA
Authorized Official - Middle Name:M
Authorized Official - Last Name:RODRIGUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:734-426-8292
Mailing Address - Street 1:3288 BROAD ST
Mailing Address - Street 2:
Mailing Address - City:DEXTER
Mailing Address - State:MI
Mailing Address - Zip Code:48130-1153
Mailing Address - Country:US
Mailing Address - Phone:734-426-8292
Mailing Address - Fax:
Practice Address - Street 1:3288 BROAD ST
Practice Address - Street 2:
Practice Address - City:DEXTER
Practice Address - State:MI
Practice Address - Zip Code:48130-1153
Practice Address - Country:US
Practice Address - Phone:734-426-8292
Practice Address - Fax:734-426-9059
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-04
Last Update Date:2008-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901018189122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty