Healthcare Provider Details

I. General information

NPI: 1225525272
Provider Name (Legal Business Name): SIMON ABRAHAM BRODSKY DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/16/2018
Last Update Date: 04/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5021 NW 34TH BLVD STE A
GAINESVILLE FL
32605-1191
US

IV. Provider business mailing address

1346 PRESERVATION WAY
OLDSMAR FL
34677-4824
US

V. Phone/Fax

Practice location:
  • Phone: 352-371-7766
  • Fax:
Mailing address:
  • Phone: 727-686-1032
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number23232
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: