Provider Demographics
NPI:1194176065
Name:ROSENTHAL, AIDA MARATOVNA
Entity type:Individual
Prefix:
First Name:AIDA
Middle Name:MARATOVNA
Last Name:ROSENTHAL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:AIDA
Other - Middle Name:
Other - Last Name:FAKHRUTDINOVA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:29402 LAUREL DR
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48331-2828
Mailing Address - Country:US
Mailing Address - Phone:248-228-0907
Mailing Address - Fax:
Practice Address - Street 1:29402 LAUREL DR
Practice Address - Street 2:
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48331-2828
Practice Address - Country:US
Practice Address - Phone:248-228-0907
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-22
Last Update Date:2017-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY059368122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program