MEDICARE: COLBY TROY BROADBENT DDS

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	6965	OK

General Provider Information

NPI Number	:	1558882548
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	COLBY TROY BROADBENT DDS

Provider Business Mailing Address
First Line	:	5810 E SKELLY DR STE 1800
Second Line	:
City	:	TULSA
State	:	OK
Zip	:	74135-6434
Country	:	US
Telephone Number	:	918-998-0996
Fax Number	:

Provider Business Practice Location Address
First Line	:	1512 SW 89TH ST
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73159-6307
Country	:	US
Telephone Number	:	405-631-2700
Fax Number	:	405-631-2701

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/29/2017
Last Update Date	:	06/16/2018

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