Provider Demographics
NPI:1316060833
Name:DR. STEPHEN E. BROAD DDS PC.
Entity type:Organization
Organization Name:DR. STEPHEN E. BROAD DDS PC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:EDWIN
Authorized Official - Last Name:BROAD
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:319-366-8521
Mailing Address - Street 1:1055 N CENTER POINT RD
Mailing Address - Street 2:
Mailing Address - City:HIAWATHA
Mailing Address - State:IA
Mailing Address - Zip Code:52233-1231
Mailing Address - Country:US
Mailing Address - Phone:319-366-8521
Mailing Address - Fax:319-393-2854
Practice Address - Street 1:1055 N CENTER POINT RD
Practice Address - Street 2:
Practice Address - City:HIAWATHA
Practice Address - State:IA
Practice Address - Zip Code:52233-1231
Practice Address - Country:US
Practice Address - Phone:319-366-8521
Practice Address - Fax:319-393-2854
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-09
Last Update Date:2008-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA064771223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty