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

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1922218684
- **Authorized official:** DR. DERRICK M BROADAWAY D.D.S. (PRACTICE OWNER)
- **Authorized official phone:** (757) 686-3033

## Contact information

- **Practice address:** 3325 TAYLOR RD, SUITE 111, CHESAPEAKE, VA 23321-3300
- **Practice address phone:** (757) 686-3033
- **Mailing address:** 3325 TAYLOR RD, SUITE 111, CHESAPEAKE, VA 23321-3300
- **Mailing address phone:** (757) 686-3033

## Taxonomy

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

## Other

- **Enumeration date:** 05/23/2007
- **Last updated:** 08/22/2020

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 01 | — | 000000005259 | DENTAL BENEFITS PROV\# | VA |
| 05 | — | 005094 | — | VA |
| 01 | — | 864302 | UNITED CONC PROV \# | VA |