1639222466 NPI number — BROADWAY DENTAL PSC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639222466 NPI number — BROADWAY DENTAL PSC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BROADWAY DENTAL PSC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1639222466
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/18/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1813 WEST BROADWAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOUISVILLE
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
40203
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
502-772-7531
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1813 WEST BROADWAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOUISVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40203
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-772-7531
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/18/2007

Additional Information

Authorized Official

Authorized Official Last Name:
FULTZ
Authorized Official First Name:
RODNEY
Authorized Official Middle Name:
BRENT
Authorized Official Title or Position:
SEC TREASURER
Authorized Official Telephone Number:
502-772-7531

Provider Taxonomy Codes

  • Taxonomy code: 122300000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 61941878 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".




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