Provider Demographics
NPI:1902983018
Name:BROADWAY, CHARLES ESTES (DMD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:ESTES
Last Name:BROADWAY
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1141 S EUSTIS ST
Mailing Address - Street 2:
Mailing Address - City:EUSTIS
Mailing Address - State:FL
Mailing Address - Zip Code:32726-5558
Mailing Address - Country:US
Mailing Address - Phone:352-589-2099
Mailing Address - Fax:352-589-6046
Practice Address - Street 1:1141 S EUSTIS ST
Practice Address - Street 2:
Practice Address - City:EUSTIS
Practice Address - State:FL
Practice Address - Zip Code:32726-5558
Practice Address - Country:US
Practice Address - Phone:352-589-2099
Practice Address - Fax:352-589-6046
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN88291223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice