Provider Demographics
NPI:1720204969
Name:BADGETT, CHOCTAW BRODIE (DMD)
Entity Type:Individual
Prefix:
First Name:CHOCTAW
Middle Name:BRODIE
Last Name:BADGETT
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:PO BOX 241
Mailing Address - Street 2:
Mailing Address - City:LEWISPORT
Mailing Address - State:KY
Mailing Address - Zip Code:42351-0241
Mailing Address - Country:US
Mailing Address - Phone:270-295-3711
Mailing Address - Fax:270-295-3716
Practice Address - Street 1:8340 U.S. 60 WEST
Practice Address - Street 2:
Practice Address - City:LEWISPORT
Practice Address - State:KY
Practice Address - Zip Code:42351
Practice Address - Country:US
Practice Address - Phone:270-926-1229
Practice Address - Fax:270-295-3716
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-17
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYKY. 4697122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY60046976Medicaid