Healthcare Provider Details

I. General information

NPI: 1801072905
Provider Name (Legal Business Name): ROBERTA JO BROMAN R.D.H.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: BOBBIE BROMAN RDH

II. Dates (important events)

Enumeration Date: 01/18/2008
Last Update Date: 08/29/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1215 N 15TH ST
CANON CITY CO
81212-4620
US

IV. Provider business mailing address

3202 N 5TH ST
CANON CITY CO
81212
US

V. Phone/Fax

Practice location:
  • Phone: 719-269-7194
  • Fax:
Mailing address:
  • Phone: 719-671-5110
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberDH903830
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: