Provider Demographics
NPI:1790318152
Name:RODRIGUEZ-LICHTENBERG, KEVIN MANUEL (DDS, MPH)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:MANUEL
Last Name:RODRIGUEZ-LICHTENBERG
Suffix:
Gender:M
Credentials:DDS, MPH
Other - Prefix:DR
Other - First Name:KEVIN
Other - Middle Name:MANUEL
Other - Last Name:RODRIGUEZ SANTOS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS, MPH
Mailing Address - Street 1:PO BOX 1978
Mailing Address - Street 2:
Mailing Address - City:SALISBURY
Mailing Address - State:MD
Mailing Address - Zip Code:21802-1978
Mailing Address - Country:US
Mailing Address - Phone:410-749-1015
Mailing Address - Fax:410-749-0654
Practice Address - Street 1:12165 ELM ST
Practice Address - Street 2:
Practice Address - City:PRINCESS ANNE
Practice Address - State:MD
Practice Address - Zip Code:21853-1358
Practice Address - Country:US
Practice Address - Phone:410-749-1015
Practice Address - Fax:410-749-0654
Is Sole Proprietor?:No
Enumeration Date:2020-02-13
Last Update Date:2023-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401417104122300000X
MD173581223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD119591300Medicaid