Provider Demographics
NPI:1982717781
Name:BROADWELL, BEVERLY R (DDS PLLC)
Entity type:Individual
Prefix:DR
First Name:BEVERLY
Middle Name:R
Last Name:BROADWELL
Suffix:
Gender:F
Credentials:DDS PLLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1921 CONCORD LAKE ROAD
Mailing Address - Street 2:
Mailing Address - City:KANNAPOLIS
Mailing Address - State:NC
Mailing Address - Zip Code:28083
Mailing Address - Country:US
Mailing Address - Phone:704-723-9252
Mailing Address - Fax:704-793-4531
Practice Address - Street 1:1921 CONCORD LAKE ROAD
Practice Address - Street 2:
Practice Address - City:KANNAPOLIS
Practice Address - State:NC
Practice Address - Zip Code:28083
Practice Address - Country:US
Practice Address - Phone:704-723-9252
Practice Address - Fax:704-793-4531
Is Sole Proprietor?:No
Enumeration Date:2006-08-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC67541223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice