Healthcare Provider Details

I. General information

NPI: 1245205863
Provider Name (Legal Business Name): MARILYN EUGENIA BRADDOCK DDS, MS, MHA
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 02/17/2006
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

USS GEORGE WASHINGTON CVN 73 DENTAL DEPT. , BOX 66
FPO AE
09550-2873
US

IV. Provider business mailing address

5311 SPY GLASS DR
NORFOLK VA
23518-6305
US

V. Phone/Fax

Practice location:
  • Phone: 757-962-4537
  • Fax:
Mailing address:
  • Phone: 757-962-4537
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number0401006086
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: