Provider Demographics
NPI:1114017530
Name:DRS BRODERICK VAUGHT & DUSEK PC
Entity Type:Organization
Organization Name:DRS BRODERICK VAUGHT & DUSEK PC
Other - Org Name:THOMAS R BRODERICK ROBERT A VAUGHT MARK W DUSEK
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:R
Authorized Official - Last Name:BRODERICK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS MS
Authorized Official - Phone:912-355-7022
Mailing Address - Street 1:500 EISENHOWER DRIVE
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31406
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:500 EISENHOWER DRIVE
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31406
Practice Address - Country:US
Practice Address - Phone:912-355-7022
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0100061223X0400X
GADN0111211223X0400X
GADN0120581223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00536335AMedicaid