Provider Demographics
NPI:1548301153
Name:BRODWIN, BENNETT ROY (DMD)
Entity type:Individual
Prefix:DR
First Name:BENNETT
Middle Name:ROY
Last Name:BRODWIN
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 1:900 COLUSA AVE
Mailing Address - Street 2:SUITE 205A
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94707-2319
Mailing Address - Country:US
Mailing Address - Phone:510-525-4847
Mailing Address - Fax:
Practice Address - Street 1:900 COLUSA AVE
Practice Address - Street 2:SUITE 205A
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94707-2319
Practice Address - Country:US
Practice Address - Phone:510-525-4847
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-08
Last Update Date:2013-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA29215122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist