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Organization
DERRICK M. BROADAWAY, D.D.S., PC
Active
Organization
DERRICK M. BROADAWAY, D.D.S., PC
Active
Parent organization
DERRICK M. BROADAWAY, D.D.S., PC
Organization subpart
Yes
Provider details
NPI number
Legal business name
DERRICK M. BROADAWAY, D.D.S., PC
Authorized official
MS. JOYCE S DAVIS CDPMA (OFFICE MANAGER)
(757) 471-6672
Entity
Organization
Contact information
Practice address
3809 PRINCESS ANNE RD, SUITE 111, VIRGINIA BEACH, VA 23456-1900
(757) 471-6672
Mailing address
3809 PRINCESS ANNE RD, SUITE 111, VIRGINIA BEACH, VA 23456-1900
(757) 471-6672
Taxonomy
Speciality
Code
Description
License number
State
1223G0001X
General Practice Dentistry
Primary
—
VA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000000005259
DENTAL BENEFITS PROVIDER#
VA
05
—
106546
—
VA
01
—
219275
BLUE CROSS PROVIDER #
VA
01
—
619881
UNITED CONCORDIA PROVIDER
VA
Enumeration date
05/21/2007
Last updated
04/07/2008
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