Provider Demographics
NPI:1336292952
Name:BROADAWAY, DERRICK MAURICE (DDS)
Entity Type:Individual
Prefix:DR
First Name:DERRICK
Middle Name:MAURICE
Last Name:BROADAWAY
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 1:3709 KECOUGHTAN RD
Mailing Address - Street 2:
Mailing Address - City:HAMPTON
Mailing Address - State:VA
Mailing Address - Zip Code:23669-4405
Mailing Address - Country:US
Mailing Address - Phone:757-722-8507
Mailing Address - Fax:757-690-8765
Practice Address - Street 1:3709 KECOUGHTAN RD
Practice Address - Street 2:
Practice Address - City:HAMPTON
Practice Address - State:VA
Practice Address - Zip Code:23669-4405
Practice Address - Country:US
Practice Address - Phone:757-722-8507
Practice Address - Fax:757-690-8765
Is Sole Proprietor?:No
Enumeration Date:2007-01-18
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04010079771223G0001X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
VI106546Medicaid