Provider Demographics
NPI:1336434661
Name:BROADBENT, JEFFREY P (DMD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:P
Last Name:BROADBENT
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:COLLEGE PARK PLAZA HARRISON 3590
Mailing Address - Street 2:SUITE 5
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84403
Mailing Address - Country:US
Mailing Address - Phone:801-621-1440
Mailing Address - Fax:801-394-6833
Practice Address - Street 1:3590 HARRISON BLVD
Practice Address - Street 2:SUITE 5
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84403-2060
Practice Address - Country:US
Practice Address - Phone:801-621-1440
Practice Address - Fax:801-394-6833
Is Sole Proprietor?:No
Enumeration Date:2011-06-15
Last Update Date:2011-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5329002-9922122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist