Provider Demographics
NPI:1538399316
Name:ATWOOD, BRODIE STEVEN (DMD)
Entity type:Individual
Prefix:DR
First Name:BRODIE
Middle Name:STEVEN
Last Name:ATWOOD
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 1:1759 W BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83402-3045
Mailing Address - Country:US
Mailing Address - Phone:208-313-0520
Mailing Address - Fax:
Practice Address - Street 1:1759 W BROADWAY ST
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83402-3045
Practice Address - Country:US
Practice Address - Phone:208-313-0520
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-15
Last Update Date:2011-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IDD4289122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program