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General NPI Number Information
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NPI Number | 1528359536
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Entity Type | Organization
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Legal Business Name | BROADMOOR FAMILY DENTISTRY
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Dates
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Enumeration Date | 04/25/2011
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Last Update Date | 04/25/2011
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Provider Practice Location Address
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Address Line | 230 CARROLL ST #4
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City | SHREVEPORT
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State | LA
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Zip | 71105-4248
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Country | US
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Telephone | 318-865-3311
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Fax | 318-865-3339
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Provider Business Mailing Address
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Address Line | 230 CARROLL ST #4
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City | SHREVEPORT
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State | LA
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Zip | 71105-4248
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Country | US
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Telephone | 318-865-3311
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Fax | 318-865-3339
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Authorized Official
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Title or Position | DENTIST
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Name | JENNIFER RIDDELL COOPER
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Credential | DDS
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Telephone | 318-865-3311
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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 | 5859
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License Number State | LA
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Taxonomy #2
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 5424
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License Number State | LA
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