Provider Demographics
NPI:1821062746
Name:BRODERSON, STEPHEN PAUL (DDS)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:PAUL
Last Name:BRODERSON
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 1:7 AVENIDA VISTA GRANDE
Mailing Address - Street 2:NO.108
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87508-9198
Mailing Address - Country:US
Mailing Address - Phone:505-757-3456
Mailing Address - Fax:505-757-3456
Practice Address - Street 1:7 AVENIDA VISTA GRANDE
Practice Address - Street 2:NO.108
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87508-9198
Practice Address - Country:US
Practice Address - Phone:505-757-3456
Practice Address - Fax:505-757-3456
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM23181223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice