Provider Demographics
NPI:1427417328
Name:BROADWAY SMILES
Entity Type:Organization
Organization Name:BROADWAY SMILES
Other - Org Name:BROADWAY SMILES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARLENE
Authorized Official - Middle Name:
Authorized Official - Last Name:THOMPSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:760-480-5622
Mailing Address - Street 1:126 W EL NORTE PKWY
Mailing Address - Street 2:
Mailing Address - City:ESCONDIDO
Mailing Address - State:CA
Mailing Address - Zip Code:92026-2502
Mailing Address - Country:US
Mailing Address - Phone:760-480-5622
Mailing Address - Fax:760-480-5623
Practice Address - Street 1:126 W EL NORTE PKWY
Practice Address - Street 2:
Practice Address - City:ESCONDIDO
Practice Address - State:CA
Practice Address - Zip Code:92026-2502
Practice Address - Country:US
Practice Address - Phone:760-480-5622
Practice Address - Fax:760-480-5623
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NC FAMILY DENTAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-02-19
Last Update Date:2016-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA50382305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization