1366733644 NPI number — BROADWAY FAMILY AND COSMETIC DENTISTRY PSC

Table of content: (NPI 1366733644)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366733644 NPI number — BROADWAY FAMILY AND COSMETIC DENTISTRY PSC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BROADWAY FAMILY AND COSMETIC DENTISTRY 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:
1366733644
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/21/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
556 N BROADWAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LEXINGTON
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
40508-1761
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
859-253-3242
Provider Business Mailing Address Fax Number:
859-253-0025

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
556 N BROADWAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LEXINGTON
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40508-1761
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
859-253-3242
Provider Business Practice Location Address Fax Number:
859-253-0025
Provider Enumeration Date:
04/21/2011

Additional Information

Authorized Official

Authorized Official Last Name:
NELSON
Authorized Official First Name:
APRILLE
Authorized Official Middle Name:
RASHEDA
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
859-253-3242

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  8731 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 7100149080 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com