Healthcare Provider Details

I. General information

NPI: 1336292952
Provider Name (Legal Business Name): DERRICK MAURICE BROADAWAY DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/18/2007
Last Update Date: 11/27/2023
Certification Date: 06/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3709 KECOUGHTAN RD
HAMPTON VA
23669-4405
US

IV. Provider business mailing address

3709 KECOUGHTAN RD
HAMPTON VA
23669-4405
US

V. Phone/Fax

Practice location:
  • Phone: 757-722-8507
  • Fax: 757-690-8765
Mailing address:
  • Phone: 757-722-8507
  • Fax: 757-690-8765

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number0401007977
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: