Provider Demographics
NPI:1811187362
Name:BROADHEAD, FREDERICK WRIGHT (DMD)
Entity Type:Individual
Prefix:DR
First Name:FREDERICK
Middle Name:WRIGHT
Last Name:BROADHEAD
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 1:80 W 4TH ST
Mailing Address - Street 2:
Mailing Address - City:FRONT ROYAL
Mailing Address - State:VA
Mailing Address - Zip Code:22630-2608
Mailing Address - Country:US
Mailing Address - Phone:540-635-4567
Mailing Address - Fax:540-635-6177
Practice Address - Street 1:80 W 4TH ST
Practice Address - Street 2:
Practice Address - City:FRONT ROYAL
Practice Address - State:VA
Practice Address - Zip Code:22630-2608
Practice Address - Country:US
Practice Address - Phone:540-635-4567
Practice Address - Fax:540-635-6177
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-31
Last Update Date:2007-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401411086122300000X
SC4053122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist