Provider Demographics
NPI:1689679383
Name:BROADWELL, BRIAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:
Last Name:BROADWELL
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 1:8535 FERN AVE
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71105-5656
Mailing Address - Country:US
Mailing Address - Phone:318-798-3376
Mailing Address - Fax:318-798-3310
Practice Address - Street 1:8535 FERN AVE
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71105-5656
Practice Address - Country:US
Practice Address - Phone:318-798-3376
Practice Address - Fax:318-798-3310
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA53131223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice