Provider Demographics
NPI:1740367879
Name:CHARLES E BROADWAY, DMD, PA
Entity type:Organization
Organization Name:CHARLES E BROADWAY, DMD, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:ESTES
Authorized Official - Last Name:BROADWAY
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:352-589-2099
Mailing Address - Street 1:1141 S EUSTIS ST
Mailing Address - Street 2:
Mailing Address - City:EUSTIS
Mailing Address - State:FL
Mailing Address - Zip Code:32726-5558
Mailing Address - Country:US
Mailing Address - Phone:352-589-2099
Mailing Address - Fax:352-589-6046
Practice Address - Street 1:1141 S EUSTIS ST
Practice Address - Street 2:
Practice Address - City:EUSTIS
Practice Address - State:FL
Practice Address - Zip Code:32726-5558
Practice Address - Country:US
Practice Address - Phone:352-589-2099
Practice Address - Fax:352-589-6046
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN88291223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty