Provider Demographics
NPI:1497258354
Name:BROADWAY DENTAL, LLC
Entity Type:Organization
Organization Name:BROADWAY DENTAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:AYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:LAWSON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:918-448-6083
Mailing Address - Street 1:114 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WILBURTON
Mailing Address - State:OK
Mailing Address - Zip Code:74578-4044
Mailing Address - Country:US
Mailing Address - Phone:918-465-3535
Mailing Address - Fax:918-465-3535
Practice Address - Street 1:2104 N BROADWAY ST
Practice Address - Street 2:
Practice Address - City:POTEAU
Practice Address - State:OK
Practice Address - Zip Code:74953-2501
Practice Address - Country:US
Practice Address - Phone:918-647-7080
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-16
Last Update Date:2018-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK58091223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty