Provider Demographics
NPI:1982839676
Name:BROADBENT, JUSTIN (DDS)
Entity Type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:
Last Name:BROADBENT
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 1:1344 S 800 E STE 220
Mailing Address - Street 2:
Mailing Address - City:OREM
Mailing Address - State:UT
Mailing Address - Zip Code:84097-5503
Mailing Address - Country:US
Mailing Address - Phone:317-777-0096
Mailing Address - Fax:
Practice Address - Street 1:1344 S 800 E STE 220
Practice Address - Street 2:
Practice Address - City:OREM
Practice Address - State:UT
Practice Address - Zip Code:84097-5503
Practice Address - Country:US
Practice Address - Phone:317-777-0096
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-05-25
Last Update Date:2013-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7384987-9921122300000X
CO10174122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist