Provider Demographics
NPI:1437238607
Name:BROADWAY GENTLE DENTISTRY PC
Entity Type:Organization
Organization Name:BROADWAY GENTLE DENTISTRY PC
Other - Org Name:BE GENTLE DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:T
Authorized Official - Last Name:MAMARIL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:765-453-9389
Mailing Address - Street 1:2302 S DIXON RD STE 125
Mailing Address - Street 2:
Mailing Address - City:KOKOMO
Mailing Address - State:IN
Mailing Address - Zip Code:46902-6425
Mailing Address - Country:US
Mailing Address - Phone:765-453-9389
Mailing Address - Fax:765-453-9369
Practice Address - Street 1:2302 S DIXON RD STE 125
Practice Address - Street 2:
Practice Address - City:KOKOMO
Practice Address - State:IN
Practice Address - Zip Code:46902-6425
Practice Address - Country:US
Practice Address - Phone:765-453-9389
Practice Address - Fax:765-453-9369
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-06
Last Update Date:2014-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN54001486A1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty