Provider Demographics
NPI:1477245371
Name:BROADWAY DENTAL WELLNESS PLLC
Entity Type:Organization
Organization Name:BROADWAY DENTAL WELLNESS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANDRES
Authorized Official - Middle Name:
Authorized Official - Last Name:SETAPUTRI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:734-250-1473
Mailing Address - Street 1:1510 N BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:HASTINGS
Mailing Address - State:MI
Mailing Address - Zip Code:49058-3024
Mailing Address - Country:US
Mailing Address - Phone:269-945-3358
Mailing Address - Fax:
Practice Address - Street 1:1510 N BROADWAY ST
Practice Address - Street 2:
Practice Address - City:HASTINGS
Practice Address - State:MI
Practice Address - Zip Code:49058-3024
Practice Address - Country:US
Practice Address - Phone:269-945-3358
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-05-22
Last Update Date:2023-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty