Provider Demographics
NPI:1326230772
Name:MATTHEW R. BROKAW, D.D.S., P.C.
Entity Type:Organization
Organization Name:MATTHEW R. BROKAW, D.D.S., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/SECRETARY/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:REED
Authorized Official - Last Name:BROKAW
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:804-270-6200
Mailing Address - Street 1:4924 DOMINION BLVD
Mailing Address - Street 2:SUITE B
Mailing Address - City:GLEN ALLEN
Mailing Address - State:VA
Mailing Address - Zip Code:23060-6766
Mailing Address - Country:US
Mailing Address - Phone:804-270-6200
Mailing Address - Fax:804-965-0581
Practice Address - Street 1:4924 DOMINION BLVD
Practice Address - Street 2:SUITE B
Practice Address - City:GLEN ALLEN
Practice Address - State:VA
Practice Address - Zip Code:23060-6766
Practice Address - Country:US
Practice Address - Phone:804-270-6200
Practice Address - Fax:804-965-0581
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-09
Last Update Date:2014-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401008695261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA205329OtherANTHEM BCBS
VA979564OtherUNITED CONCORDIA