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General NPI Number Information
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NPI Number | 1114017530
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Entity Type | Organization
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Legal Business Name | DRS BRODERICK VAUGHT & DUSEK PC
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Dates
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Enumeration Date | 10/14/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 500 EISENHOWER DRIVE
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City | SAVANNAH
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State | GA
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Zip | 31406
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Country | US
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Telephone | 912-355-7022
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Fax |
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Provider Business Mailing Address
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Address Line | 500 EISENHOWER DRIVE
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City | SAVANNAH
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State | GA
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Zip | 31406
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER PARTNER
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Name | DR. THOMAS R BRODERICK
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Credential | DDS MS
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Telephone | 912-355-7022
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223X0400X
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Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
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License Number | DN010006
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License Number State | GA
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Taxonomy #2
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Taxonomy Code | 1223X0400X
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Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
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License Number | DN011121
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License Number State | GA
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Taxonomy #3
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Taxonomy Code | 1223X0400X
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Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
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License Number | DN012058
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License Number State | GA
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