Healthcare Provider Details

I. General information

NPI: 1326052804
Provider Name (Legal Business Name): RICHARD STEVEN BROADBENT D.M.D, M.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/28/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2707 N 400 E
NORTH OGDEN UT
84414-2241
US

IV. Provider business mailing address

2707 N 400 E
NORTH OGDEN UT
84414-2241
US

V. Phone/Fax

Practice location:
  • Phone: 801-782-4762
  • Fax: 801-782-0183
Mailing address:
  • Phone: 801-782-4762
  • Fax: 801-782-0183

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number374026
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: