Healthcare Provider Details

I. General information

NPI: 1093749426
Provider Name (Legal Business Name): RICHARD P. BROERING JR. DMD, MS, PSC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/10/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3005 DIXIE HWY SUITE 100
EDGEWOOD KY
41017-2352
US

IV. Provider business mailing address

3005 DIXIE HWY SUITE 100
EDGEWOOD KY
41017-2352
US

V. Phone/Fax

Practice location:
  • Phone: 859-344-8000
  • Fax: 859-344-8001
Mailing address:
  • Phone: 859-344-8000
  • Fax: 859-344-8001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number6251
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: