Organization
DERRICK M. BROADAWAY, D.D.S., PC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. DERRICK M BROADAWAY D.D.S. (PRACTICE OWNER)
(757) 686-3033
Entity
Organization
Contact information
Practice address
3325 TAYLOR RD, SUITE 111, CHESAPEAKE, VA 23321-3300
(757) 686-3033
Mailing address
3325 TAYLOR RD, SUITE 111, CHESAPEAKE, VA 23321-3300
(757) 686-3033
Taxonomy
Speciality
Code
Description
License number
State
1223G0001X
General Practice Dentistry
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000000005259
DENTAL BENEFITS PROV#
VA
05
—
005094
—
VA
01
—
864302
UNITED CONC PROV #
VA
Enumeration date
05/23/2007
Last updated
08/22/2020
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