Provider Demographics
NPI:1992323760
Name:BROUGHTON, JILLIAN ELAINE (DMD)
Entity type:Individual
Prefix:DR
First Name:JILLIAN
Middle Name:ELAINE
Last Name:BROUGHTON
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1755 CENTRAL PARK RD UNIT 6209
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29412-2850
Mailing Address - Country:US
Mailing Address - Phone:843-670-8202
Mailing Address - Fax:
Practice Address - Street 1:1724 STATE RD UNIT 4D
Practice Address - Street 2:
Practice Address - City:SUMMERVILLE
Practice Address - State:SC
Practice Address - Zip Code:29486-2842
Practice Address - Country:US
Practice Address - Phone:843-352-4454
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-08
Last Update Date:2021-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC97141223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice