Provider Demographics
NPI:1316156102
Name:DERRICK M. BROADAWAY, D.D.S., PC
Entity type:Organization
Organization Name:DERRICK M. BROADAWAY, D.D.S., PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:JOYCE
Authorized Official - Middle Name:S
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:CDPMA
Authorized Official - Phone:757-471-6672
Mailing Address - Street 1:3809 PRINCESS ANNE RD
Mailing Address - Street 2:SUITE 111
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23456-1900
Mailing Address - Country:US
Mailing Address - Phone:757-471-6672
Mailing Address - Fax:
Practice Address - Street 1:3809 PRINCESS ANNE RD
Practice Address - Street 2:SUITE 111
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23456-1900
Practice Address - Country:US
Practice Address - Phone:757-471-6672
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DERRICK M. BROADAWAY, D.D.S., PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-05-21
Last Update Date:2008-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA000000005259OtherUNITED HEALTHCARE PROVIDE
VA619881OtherUNITED CONCORDIA PROVIDER
VA219275OtherBLUE CROSS PROVIDER #
VA000000005259OtherDENTAL BENEFITS PROVIDER#
VA106546Medicaid