Provider Demographics
NPI:1780650069
Name:ROBERT L BROADY DDS PC
Entity Type:Organization
Organization Name:ROBERT L BROADY DDS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:BROADY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:314-355-5851
Mailing Address - Street 1:158 MAYFAIR PLAZA
Mailing Address - Street 2:
Mailing Address - City:FLORISSANT
Mailing Address - State:MO
Mailing Address - Zip Code:63033-8008
Mailing Address - Country:US
Mailing Address - Phone:314-355-5851
Mailing Address - Fax:314-355-5852
Practice Address - Street 1:158 MAYFAIR PLAZA
Practice Address - Street 2:
Practice Address - City:FLORISSANT
Practice Address - State:MO
Practice Address - Zip Code:63033-8008
Practice Address - Country:US
Practice Address - Phone:314-355-5851
Practice Address - Fax:314-355-5852
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO12980122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty