Provider Demographics
NPI:1982705109
Name:BROKAW, MATTHEW REED (DDS)
Entity type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:REED
Last Name:BROKAW
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 1:4924 DOMINION BLVD
Mailing Address - Street 2:SUITE B
Mailing Address - City:GLEN ALLEN
Mailing Address - State:VA
Mailing Address - Zip Code:23060-6766
Mailing Address - Country:US
Mailing Address - Phone:804-270-6200
Mailing Address - Fax:804-965-0581
Practice Address - Street 1:4924 DOMINION BLVD
Practice Address - Street 2:SUITE B
Practice Address - City:GLEN ALLEN
Practice Address - State:VA
Practice Address - Zip Code:23060-6766
Practice Address - Country:US
Practice Address - Phone:804-270-6200
Practice Address - Fax:804-965-0581
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2014-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04010086951223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA979564OtherUNITED CONCORDIA
VA205329OtherANTHEM BCBS