Provider Demographics
NPI:1174704837
Name:BROADFOOT, JAMES CHARLES (DMD)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:CHARLES
Last Name:BROADFOOT
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 1:414 PENDLETON PL
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31602-2603
Mailing Address - Country:US
Mailing Address - Phone:229-244-3700
Mailing Address - Fax:229-247-0373
Practice Address - Street 1:414 PENDLETON PL
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602-2603
Practice Address - Country:US
Practice Address - Phone:229-244-3700
Practice Address - Fax:229-247-0373
Is Sole Proprietor?:No
Enumeration Date:2007-11-21
Last Update Date:2007-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN013666122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist