Provider Demographics
NPI:1922453539
Name:BRODSKY, MEGHAN (DDS)
Entity Type:Individual
Prefix:
First Name:MEGHAN
Middle Name:
Last Name:BRODSKY
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9915 PINE VALLEY TRL
Mailing Address - Street 2:
Mailing Address - City:BRIGHTON
Mailing Address - State:MI
Mailing Address - Zip Code:48114-8964
Mailing Address - Country:US
Mailing Address - Phone:810-962-0084
Mailing Address - Fax:
Practice Address - Street 1:12500 E 12 MILE RD
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48093
Practice Address - Country:US
Practice Address - Phone:586-573-6677
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-02
Last Update Date:2018-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MD163671223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program