Provider Demographics
NPI:1841403953
Name:BRODERICK, JOHN G (DMD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:G
Last Name:BRODERICK
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 1:200 HEROUX BLVD UNIT 507
Mailing Address - Street 2:
Mailing Address - City:CUMBERLAND
Mailing Address - State:RI
Mailing Address - Zip Code:02864-2384
Mailing Address - Country:US
Mailing Address - Phone:401-954-7760
Mailing Address - Fax:401-421-7875
Practice Address - Street 1:167 GANO ST
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02906-3808
Practice Address - Country:US
Practice Address - Phone:401-274-2600
Practice Address - Fax:401-421-7875
Is Sole Proprietor?:No
Enumeration Date:2007-05-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIDEN027001223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics