Provider Demographics
NPI:1922218684
Name:DERRICK M. BROADAWAY, D.D.S., PC
Entity Type:Organization
Organization Name:DERRICK M. BROADAWAY, D.D.S., PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DERRICK
Authorized Official - Middle Name:M
Authorized Official - Last Name:BROADAWAY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:757-686-3033
Mailing Address - Street 1:3325 TAYLOR RD
Mailing Address - Street 2:SUITE 111
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23321-3300
Mailing Address - Country:US
Mailing Address - Phone:757-686-3033
Mailing Address - Fax:
Practice Address - Street 1:3325 TAYLOR RD
Practice Address - Street 2:SUITE 111
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23321-3300
Practice Address - Country:US
Practice Address - Phone:757-686-3033
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA000000005259OtherDENTAL BENEFITS PROV#
VA005094Medicaid
VA000000005259OtherUNITED HEALTHCARE PROV#
VA864302OtherUNITED CONC PROV #