Provider Demographics
NPI:1326052804
Name:BROADBENT, RICHARD STEVEN (DMD, MS)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:STEVEN
Last Name:BROADBENT
Suffix:
Gender:M
Credentials:DMD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2707 N 400 E
Mailing Address - Street 2:
Mailing Address - City:NORTH OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84414-2241
Mailing Address - Country:US
Mailing Address - Phone:801-782-4762
Mailing Address - Fax:801-782-0183
Practice Address - Street 1:2707 N 400 E
Practice Address - Street 2:
Practice Address - City:NORTH OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84414-2241
Practice Address - Country:US
Practice Address - Phone:801-782-4762
Practice Address - Fax:801-782-0183
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT3740261223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics