Provider Demographics
NPI:1609856509
Name:BRODY, DANIEL (DDS)
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:
Last Name:BRODY
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 1:2585 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25703-1642
Mailing Address - Country:US
Mailing Address - Phone:304-697-1396
Mailing Address - Fax:304-697-2086
Practice Address - Street 1:#71 WAYNE STREET
Practice Address - Street 2:
Practice Address - City:FORT GAY
Practice Address - State:WV
Practice Address - Zip Code:25514-8518
Practice Address - Country:US
Practice Address - Phone:304-648-5433
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-18
Last Update Date:2024-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV2768122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY60690237Medicaid
WV0137071000Medicaid
OH0068952Medicaid