Provider Demographics
NPI:1720235781
Name:BRODAL, CLINT OLE (DMD)
Entity Type:Individual
Prefix:DR
First Name:CLINT
Middle Name:OLE
Last Name:BRODAL
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 1:121 PARLIAMENT DR
Mailing Address - Street 2:
Mailing Address - City:MARYVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37804-6210
Mailing Address - Country:US
Mailing Address - Phone:865-977-8700
Mailing Address - Fax:865-977-5464
Practice Address - Street 1:121 PARLIAMENT DR
Practice Address - Street 2:
Practice Address - City:MARYVILLE
Practice Address - State:TN
Practice Address - Zip Code:37804-6210
Practice Address - Country:US
Practice Address - Phone:865-977-8700
Practice Address - Fax:865-977-5464
Is Sole Proprietor?:No
Enumeration Date:2008-08-21
Last Update Date:2016-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD9259122300000X, 390200000X
TN102891223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program