Healthcare Provider Details

I. General information

NPI: 1528135142
Provider Name (Legal Business Name): MICHAEL BRODY DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/29/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20762 W DIXIE HWY
MIAMI FL
33180-1146
US

IV. Provider business mailing address

20762 W DIXIE HWY
MIAMI FL
33180-1146
US

V. Phone/Fax

Practice location:
  • Phone: 305-682-0045
  • Fax:
Mailing address:
  • Phone: 305-682-0045
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberDN0013389
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: