Provider Demographics
NPI:1699240879
Name:BRODINE, BRIAN ASHFORD (DDS)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:ASHFORD
Last Name:BRODINE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:118 FLEETS ISLAND DR
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38103-9032
Mailing Address - Country:US
Mailing Address - Phone:585-509-4903
Mailing Address - Fax:
Practice Address - Street 1:875 UNION AVE
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38103-3513
Practice Address - Country:US
Practice Address - Phone:585-509-4903
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-03
Last Update Date:2018-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN107681223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN10768OtherFEE FOR SERVICE