Provider Demographics
NPI:1417243411
Name:BRODERICK, CARRIEANN REWKOWSKI (DMD)
Entity Type:Individual
Prefix:DR
First Name:CARRIEANN
Middle Name:REWKOWSKI
Last Name:BRODERICK
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 SCHUBERT DR
Mailing Address - Street 2:
Mailing Address - City:DOWNINGTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:19335-3382
Mailing Address - Country:US
Mailing Address - Phone:610-269-3978
Mailing Address - Fax:610-269-9670
Practice Address - Street 1:104 SCHUBERT DR
Practice Address - Street 2:
Practice Address - City:DOWNINGTOWN
Practice Address - State:PA
Practice Address - Zip Code:19335-3382
Practice Address - Country:US
Practice Address - Phone:610-269-3978
Practice Address - Fax:610-269-9670
Is Sole Proprietor?:No
Enumeration Date:2011-06-28
Last Update Date:2021-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS037001122300000X
FLDN17853122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist