Provider Demographics
NPI:1063085413
Name:BRODERICK, TINA ANDREA (RDH)
Entity type:Individual
Prefix:
First Name:TINA
Middle Name:ANDREA
Last Name:BRODERICK
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5395
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87502-5395
Mailing Address - Country:US
Mailing Address - Phone:505-984-5048
Mailing Address - Fax:505-988-3246
Practice Address - Street 1:6401 S RICHARDS AVE
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87508-4887
Practice Address - Country:US
Practice Address - Phone:505-984-5048
Practice Address - Fax:505-988-3246
Is Sole Proprietor?:No
Enumeration Date:2021-07-22
Last Update Date:2021-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
124Q00000X
NMDH1049124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist