MEDICARE: DERRICK M. BROADAWAY, D.D.S., PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry		VA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	000000005259	OTHER	VA	UNITED HEALTHCARE PROVIDE
2	619881	OTHER	VA	UNITED CONCORDIA PROVIDER
3	219275	OTHER	VA	BLUE CROSS PROVIDER #
4	000000005259	OTHER	VA	DENTAL BENEFITS PROVIDER#
5	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1316156102
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DERRICK M. BROADAWAY, D.D.S., PC

Provider Business Mailing Address
First Line	:	3809 PRINCESS ANNE RD
Second Line	:	SUITE 111
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23456-1900
Country	:	US
Telephone Number	:	757-471-6672
Fax Number	:

Provider Business Practice Location Address
First Line	:	3809 PRINCESS ANNE RD
Second Line	:	SUITE 111
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23456-1900
Country	:	US
Telephone Number	:	757-471-6672
Fax Number	:

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	MS. JOYCE S DAVIS
Credential	:	CDPMA
Telephone Number	:	757-471-6672

Provider Enumeration Date	:	05/21/2007
Last Update Date	:	04/07/2008

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Directions to “DERRICK M. BROADAWAY, D.D.S., PC ” Practice Location

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