Healthcare Provider Details

I. General information

NPI: 1083266639
Provider Name (Legal Business Name): JORDAN E BROADDUS DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2019
Last Update Date: 03/08/2023
Certification Date: 03/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6976 OLD CUSSETA HIGHWAY
FT BENNING GA
31905
US

IV. Provider business mailing address

6976 OLD CUSSETA HIGHWAY
FT BENNING GA
31905
US

V. Phone/Fax

Practice location:
  • Phone: 706-544-3176
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number10326
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number10326
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: