Individual
MS. MARY RACHELLE BRODERICK
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
RDH
Contact information
Practice address
6419 LAKE RD, APPLETON, NY 14008-9606
(716) 297-0798
(716) 297-0998
Mailing address
6419 LAKE RD, APPLETON, NY 14008-9606
(716) 297-0798
(716) 297-0998
Taxonomy
Speciality
Code
Description
License number
State
124Q00000X
Dental Hygienist
Primary
016112-1
NY
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
016112-1
NEW YORK STATE LICENSE
NY
Enumeration date
09/13/2011
Last updated
09/13/2011
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