Provider Demographics
NPI:1194835215
Name:BROGDON, STEPHEN GATLIN (DDS)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:GATLIN
Last Name:BROGDON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3646 GRANBURY RD
Mailing Address - Street 2:SUITE 104
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76109-3717
Mailing Address - Country:US
Mailing Address - Phone:817-923-4606
Mailing Address - Fax:817-923-5593
Practice Address - Street 1:3646 GRANBURY RD
Practice Address - Street 2:SUITE 104
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76109-3717
Practice Address - Country:US
Practice Address - Phone:817-923-4606
Practice Address - Fax:817-923-5593
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX171781223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice