Provider Demographics
NPI:1083266639
Name:BROADDUS, JORDAN E (DMD)
Entity Type:Individual
Prefix:DR
First Name:JORDAN
Middle Name:E
Last Name:BROADDUS
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6976 OLD CUSSETA HIGHWAY
Mailing Address - Street 2:
Mailing Address - City:FT BENNING
Mailing Address - State:GA
Mailing Address - Zip Code:31905
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6976 OLD CUSSETA HIGHWAY
Practice Address - Street 2:
Practice Address - City:FT BENNING
Practice Address - State:GA
Practice Address - Zip Code:31905
Practice Address - Country:US
Practice Address - Phone:706-544-3176
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-14
Last Update Date:2023-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY10326122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice