1821062746 NPI number — DR. STEPHEN PAUL BRODERSON D.D.S.

Table of content: DR. STEPHEN PAUL BRODERSON D.D.S. (NPI 1821062746)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821062746 NPI number — DR. STEPHEN PAUL BRODERSON D.D.S.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BRODERSON
Provider First Name:
STEPHEN
Provider Middle Name:
PAUL
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.D.S.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1821062746
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7 AVENIDA VISTA GRANDE
Provider Second Line Business Mailing Address:
NO.108
Provider Business Mailing Address City Name:
SANTA FE
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87508-9198
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-757-3456
Provider Business Mailing Address Fax Number:
505-757-3456

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7 AVENIDA VISTA GRANDE
Provider Second Line Business Practice Location Address:
NO.108
Provider Business Practice Location Address City Name:
SANTA FE
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87508-9198
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-757-3456
Provider Business Practice Location Address Fax Number:
505-757-3456
Provider Enumeration Date:
02/15/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  2318 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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