Provider Demographics
NPI:1588759914
Name:BRODNER, JOHN JASON (DMD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:JASON
Last Name:BRODNER
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:399 TEQUESTA DR
Mailing Address - Street 2:SUITE 103
Mailing Address - City:TEQUESTA
Mailing Address - State:FL
Mailing Address - Zip Code:33469-3087
Mailing Address - Country:US
Mailing Address - Phone:561-746-7600
Mailing Address - Fax:561-743-9884
Practice Address - Street 1:399 TEQUESTA DR
Practice Address - Street 2:SUITE 103
Practice Address - City:TEQUESTA
Practice Address - State:FL
Practice Address - Zip Code:33469-3087
Practice Address - Country:US
Practice Address - Phone:561-746-7600
Practice Address - Fax:561-743-9884
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN149991223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice