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 1:1515 N FLAGLER DR STE 101
Mailing Address - Street 2:
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33401-3429
Mailing Address - Country:US
Mailing Address - Phone:561-642-1000
Mailing Address - Fax:561-804-5629
Practice Address - Street 1:1150 45TH ST
Practice Address - Street 2:
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33407-2361
Practice Address - Country:US
Practice Address - Phone:561-642-1000
Practice Address - Fax:561-804-5629
Is Sole Proprietor?:No
Enumeration Date:2020-02-13
Last Update Date:2024-09-19
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
FL122877100Medicaid