Healthcare Provider Details

I. General information

NPI: 1720204969
Provider Name (Legal Business Name): CHOCTAW BRODIE BADGETT DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/17/2007
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8340 U.S. 60 WEST
LEWISPORT KY
42351
US

IV. Provider business mailing address

PO BOX 241
LEWISPORT KY
42351-0241
US

V. Phone/Fax

Practice location:
  • Phone: 270-926-1229
  • Fax: 270-295-3716
Mailing address:
  • Phone: 270-295-3711
  • Fax: 270-295-3716

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberKY. 4697
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: