Provider Demographics
NPI:1245205863
Name:BRADDOCK, MARILYN EUGENIA (DDS, MS, MHA)
Entity Type:Individual
Prefix:DR
First Name:MARILYN
Middle Name:EUGENIA
Last Name:BRADDOCK
Suffix:
Gender:F
Credentials:DDS, MS, MHA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5311 SPY GLASS DR
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23518-6305
Mailing Address - Country:US
Mailing Address - Phone:757-962-4537
Mailing Address - Fax:
Practice Address - Street 1:USS GEORGE WASHINGTON CVN 73
Practice Address - Street 2:DENTAL DEPT. , BOX 66
Practice Address - City:FPO
Practice Address - State:AE
Practice Address - Zip Code:09550-2873
Practice Address - Country:US
Practice Address - Phone:757-962-4537
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-17
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04010060861223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics