Provider Demographics
NPI:1184807331
Name:BRODIE DENTAL LLC
Entity type:Organization
Organization Name:BRODIE DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:W
Authorized Official - Last Name:BRODIE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:541-899-8833
Mailing Address - Street 1:305 SHAFER LN
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97530-9681
Mailing Address - Country:US
Mailing Address - Phone:541-899-8833
Mailing Address - Fax:541-899-1769
Practice Address - Street 1:305 SHAFER LN
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:OR
Practice Address - Zip Code:97530-9681
Practice Address - Country:US
Practice Address - Phone:541-899-8833
Practice Address - Fax:541-899-1769
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-11
Last Update Date:2007-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty