Provider Demographics
NPI:1164317020
Name:BROADWATER, JORDAN (DDS)
Entity type:Individual
Prefix:DR
First Name:JORDAN
Middle Name:
Last Name:BROADWATER
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1024 FORREST RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37660-6628
Mailing Address - Country:US
Mailing Address - Phone:423-306-5052
Mailing Address - Fax:
Practice Address - Street 1:2701 BLOOMINGDALE RD
Practice Address - Street 2:
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660-1854
Practice Address - Country:US
Practice Address - Phone:423-288-8566
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-06-11
Last Update Date:2025-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN12846122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist