# DERRICK M. BROADAWAY, D.D.S., PC

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- **Entity:** Organization
- **Status:** Active
- **Parent organization:** DERRICK M. BROADAWAY, D.D.S., PC
- **Organization subpart:** Yes

## Provider details

- **NPI number:** 1316156102
- **Legal business name:** DERRICK M. BROADAWAY, D.D.S., PC
- **Authorized official:** MS. JOYCE S DAVIS CDPMA (OFFICE MANAGER)
- **Authorized official phone:** (757) 471-6672

## Contact information

- **Practice address:** 3809 PRINCESS ANNE RD, SUITE 111, VIRGINIA BEACH, VA 23456-1900
- **Practice address phone:** (757) 471-6672
- **Mailing address:** 3809 PRINCESS ANNE RD, SUITE 111, VIRGINIA BEACH, VA 23456-1900
- **Mailing address phone:** (757) 471-6672

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 1223G0001X | General Practice Dentistry | — | VA | Yes |

## Other

- **Enumeration date:** 05/21/2007
- **Last updated:** 04/07/2008

## 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 |