Provider Demographics
NPI:1295978047
Name:AZALEA CITY FAMILY DENTISTRY
Entity type:Organization
Organization Name:AZALEA CITY FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:W
Authorized Official - Last Name:BROADFOOT
Authorized Official - Suffix:JR
Authorized Official - Credentials:DDS
Authorized Official - Phone:229-244-3700
Mailing Address - Street 1:414 PENDLETON PL
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31602-2603
Mailing Address - Country:US
Mailing Address - Phone:229-244-3700
Mailing Address - Fax:229-247-0373
Practice Address - Street 1:414 PENDLETON PL
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602-2603
Practice Address - Country:US
Practice Address - Phone:229-244-3700
Practice Address - Fax:229-247-0373
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-09
Last Update Date:2009-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0079951223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty