Provider Demographics
NPI:1073626875
Name:BEVERLY BROADWELL DDS PLLC
Entity Type:Organization
Organization Name:BEVERLY BROADWELL DDS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BEVERLY
Authorized Official - Middle Name:B
Authorized Official - Last Name:BROADWELL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS PLLC
Authorized Official - Phone:704-723-9252
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty