Provider Demographics
NPI:1326371410
Name:BROADBENT, THOMAS AUSTEN (DMD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:AUSTEN
Last Name:BROADBENT
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3540 S 4000 W
Mailing Address - Street 2:SUITE #140
Mailing Address - City:WEST VALLEY
Mailing Address - State:UT
Mailing Address - Zip Code:84120-3260
Mailing Address - Country:US
Mailing Address - Phone:801-969-6200
Mailing Address - Fax:
Practice Address - Street 1:3540 S 4000 W
Practice Address - Street 2:SUITE #140
Practice Address - City:WEST VALLEY
Practice Address - State:UT
Practice Address - Zip Code:84120-3260
Practice Address - Country:US
Practice Address - Phone:801-969-6200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-08
Last Update Date:2009-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7390228-99221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice