Active NPI
Jordan Broadwater, DDS
- Dentist
- Kingsport, TN
National Provider Identifier
1164317020
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Dentist
- License
- 12846
- Practice address
- 2701 Bloomingdale Rd
Kingsport, TN 37660-1854 - Phone
- (423) 288-8566
- NPI assigned
- Jun 11, 2025
- Sex
- Male
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Dentist | 122300000X | 12846 | TN | Primary |
Addresses
Primary practice location
2701 Bloomingdale Rd
Kingsport, TN 37660-1854
Mailing address
1024 Forrest Ridge Dr
Kingsport, TN 37660-6628
Phone (423) 306-5052
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 12846 | TN | MD | Dentist |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Athens Family Dental | Dentist | Past | Accepting new patients |
Organizations & group practices 1
Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1749600000000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1749600000000",
"number": "1164317020",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "1024 FORREST RIDGE DR",
"city": "KINGSPORT",
"state": "TN",
"postal_code": "376606628",
"telephone_number": "423-306-5052"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "2701 BLOOMINGDALE RD",
"city": "KINGSPORT",
"state": "TN",
"postal_code": "376601854",
"telephone_number": "423-288-8566"
}
],
"practiceLocations": [],
"basic": {
"last_name": "BROADWATER",
"first_name": "JORDAN",
"name_prefix": "Dr.",
"credential": "DDS",
"sole_proprietor": "YES",
"sex": "M",
"enumeration_date": "2025-06-11",
"last_updated": "2025-06-11",
"certification_date": "2025-06-11",
"status": "A"
},
"taxonomies": [
{
"code": "122300000X",
"taxonomy_group": "",
"desc": "Dentist",
"state": "TN",
"license": "12846",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Kingsport, TN
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 11, 2025; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.