Provider Demographics
NPI:1205049459
Name:BROADBENT, MICHAEL WILLIAM (DMD, MS)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:WILLIAM
Last Name:BROADBENT
Suffix:
Gender:M
Credentials:DMD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3590 HARRISON BLVD
Mailing Address - Street 2:SUITE #2
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84403-2060
Mailing Address - Country:US
Mailing Address - Phone:801-392-7176
Mailing Address - Fax:
Practice Address - Street 1:3590 HARRISON BLVD
Practice Address - Street 2:SUITE #2
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84403-2060
Practice Address - Country:US
Practice Address - Phone:801-392-7176
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-07
Last Update Date:2015-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6511661-99241223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery