Healthcare Provider Details

I. General information

NPI: 1841536364
Provider Name (Legal Business Name): FREDERICK W. BROADHEAD, DMD, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/03/2013
Last Update Date: 01/03/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

80 W 4TH ST
FRONT ROYAL VA
22630-2608
US

IV. Provider business mailing address

80 W 4TH ST
FRONT ROYAL VA
22630-2608
US

V. Phone/Fax

Practice location:
  • Phone: 540-635-4567
  • Fax: 540-635-6794
Mailing address:
  • Phone: 540-635-4567
  • Fax: 540-635-6794

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number0401413785
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number0401411086
License Number StateVA

VIII. Authorized Official

Name: DR. FREDERICK WRIGHT BROADHEAD
Title or Position: OWNER
Credential: DMD
Phone: 540-635-4567