Provider Demographics
NPI:1134509458
Name:BROADWAY DENTAL CENTER, INC.
Entity Type:Organization
Organization Name:BROADWAY DENTAL CENTER, INC.
Other - Org Name:S. DAVID BUCK, DDS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:BUCK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:206-324-1100
Mailing Address - Street 1:310 HARVARD AVE. E.
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98102
Mailing Address - Country:US
Mailing Address - Phone:206-324-1100
Mailing Address - Fax:206-324-6711
Practice Address - Street 1:310 HARVARD AVE. E.
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98102
Practice Address - Country:US
Practice Address - Phone:206-324-1100
Practice Address - Fax:206-324-6711
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-02
Last Update Date:2015-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA6274261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA6274OtherDDS