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General NPI Number Information
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NPI Number | 1386186278
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Entity Type | Organization
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Legal Business Name | BROADWATER DENTAL
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Dates
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Enumeration Date | 11/09/2016
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Last Update Date | 11/09/2016
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Provider Practice Location Address
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Address Line | 2318 PASS RD STE 9
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City | BILOXI
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State | MS
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Zip | 39531-4044
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Country | US
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Telephone | 228-388-3353
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Fax | 228-388-4696
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Provider Business Mailing Address
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Address Line | 2318 PASS ROAD STE 9
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City | BILOXI
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State | MS
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Zip | 39531
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Country | US
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Telephone | 228-388-3353
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Fax | 228-388-4696
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Authorized Official
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Title or Position | DENTIST
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Name | DR. CLIFFORD J COOK
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Credential | D.M.D.
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Telephone | 228-388-3353
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | MS3497-09
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License Number State | MS
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