Provider Demographics
NPI:1558882548
Name:BROADBENT, COLBY TROY (DDS)
Entity Type:Individual
Prefix:
First Name:COLBY
Middle Name:TROY
Last Name:BROADBENT
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 1:5810 E SKELLY DR STE 1800
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74135-6434
Mailing Address - Country:US
Mailing Address - Phone:918-998-0996
Mailing Address - Fax:
Practice Address - Street 1:1512 SW 89TH ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73159-6307
Practice Address - Country:US
Practice Address - Phone:405-631-2700
Practice Address - Fax:405-631-2701
Is Sole Proprietor?:No
Enumeration Date:2017-06-29
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK69651223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice