Provider Demographics
NPI:1215219084
Name:BROADWAY DENTAL SERVICES
Entity Type:Organization
Organization Name:BROADWAY DENTAL SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MUKUKA
Authorized Official - Middle Name:
Authorized Official - Last Name:KAPILIKISHA
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:219-671-3754
Mailing Address - Street 1:1693 STILLWATER AVE
Mailing Address - Street 2:
Mailing Address - City:DYER
Mailing Address - State:IN
Mailing Address - Zip Code:46311-3088
Mailing Address - Country:US
Mailing Address - Phone:219-671-3754
Mailing Address - Fax:
Practice Address - Street 1:3195 BROADWAY
Practice Address - Street 2:
Practice Address - City:GARY
Practice Address - State:IN
Practice Address - Zip Code:46409-1006
Practice Address - Country:US
Practice Address - Phone:219-671-3754
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-16
Last Update Date:2011-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12011216A1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty