Provider Demographics
NPI:1144801622
Name:BROADWAY SMILES DENTAL, LLC
Entity Type:Organization
Organization Name:BROADWAY SMILES DENTAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:STACI
Authorized Official - Middle Name:NICOLE
Authorized Official - Last Name:OSGOOD
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:913-558-3919
Mailing Address - Street 1:6724 E 134TH ST
Mailing Address - Street 2:
Mailing Address - City:GRANDVIEW
Mailing Address - State:MO
Mailing Address - Zip Code:64030-3236
Mailing Address - Country:US
Mailing Address - Phone:913-558-3919
Mailing Address - Fax:
Practice Address - Street 1:2016 S BROADWAY # 8439
Practice Address - Street 2:
Practice Address - City:OAK GROVE
Practice Address - State:MO
Practice Address - Zip Code:64075-8439
Practice Address - Country:US
Practice Address - Phone:816-690-7757
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-04-16
Last Update Date:2021-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty