Provider Demographics
NPI:1205372265
Name:BROADWAY DENTAL CENTER
Entity Type:Organization
Organization Name:BROADWAY DENTAL CENTER
Other - Org Name:SMILE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:FINANCIAL COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:HEATHER
Authorized Official - Middle Name:
Authorized Official - Last Name:MCINTYRE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:269-445-5550
Mailing Address - Street 1:PO BOX 8
Mailing Address - Street 2:
Mailing Address - City:CASSOPOLIS
Mailing Address - State:MI
Mailing Address - Zip Code:49031-0008
Mailing Address - Country:US
Mailing Address - Phone:269-445-5550
Mailing Address - Fax:269-445-0101
Practice Address - Street 1:110 S BROADWAY ST
Practice Address - Street 2:
Practice Address - City:CASSOPOLIS
Practice Address - State:MI
Practice Address - Zip Code:49031-1243
Practice Address - Country:US
Practice Address - Phone:269-445-5550
Practice Address - Fax:269-445-0101
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-16
Last Update Date:2017-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29155661223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty