Basic Information
| Provider Information | |||||||||
| NPI: | 1063085413 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRODERICK | ||||||||
| FirstName: | TINA | ||||||||
| MiddleName: | ANDREA | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | RDH | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5395 | ||||||||
| Address2: | |||||||||
| City: | SANTA FE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 875025395 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5059845048 | ||||||||
| FaxNumber: | 5059883246 | ||||||||
| Practice Location | |||||||||
| Address1: | 6401 S RICHARDS AVE | ||||||||
| Address2: | |||||||||
| City: | SANTA FE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 875084887 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5059845048 | ||||||||
| FaxNumber: | 5059883246 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/22/2021 | ||||||||
| LastUpdateDate: | 07/22/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/22/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 124Q00000X | N | Dental Providers | Dental Hygienist | 124Q00000X | DH1049 | NM | Y | Dental Providers | Dental Hygienist |
No ID Information.