Basic Information
| Provider Information | |||||||||
| NPI: | 1609856509 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRODY | ||||||||
| FirstName: | DANIEL | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | DDS | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 2585 3RD AVE | ||||||||
| Address2: | |||||||||
| City: | HUNTINGTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 257031642 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3046971396 | ||||||||
| FaxNumber: | 3046972086 | ||||||||
| Practice Location | |||||||||
| Address1: | #71 WAYNE STREET | ||||||||
| Address2: | |||||||||
| City: | FORT GAY | ||||||||
| State: | WV | ||||||||
| PostalCode: | 255148518 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3046485433 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/18/2006 | ||||||||
| LastUpdateDate: | 11/12/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/12/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 2768 | WV | Y | Dental Providers | Dentist |
ID Information
| ID | Type | State | Issuer | Description | 0068952 | 05 | OH | MEDICAID | 60690237 | 05 | KY | MEDICAID | 0137071000 | 05 | WV | MEDICAID |