Healthcare Provider Details

I. General information

NPI: 1548301153
Provider Name (Legal Business Name): BENNETT ROY BRODWIN DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/08/2007
Last Update Date: 08/28/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 COLUSA AVE SUITE 205A
BERKELEY CA
94707-2319
US

IV. Provider business mailing address

900 COLUSA AVE SUITE 205A
BERKELEY CA
94707-2319
US

V. Phone/Fax

Practice location:
  • Phone: 510-525-4847
  • Fax:
Mailing address:
  • Phone: 510-525-4847
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number29215
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: