Provider Demographics
NPI:1568634780
Name:BROADWAY DENTAL OFFICE, P.C
Entity Type:Organization
Organization Name:BROADWAY DENTAL OFFICE, P.C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:YSABEL
Authorized Official - Middle Name:
Authorized Official - Last Name:ULERIO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:212-942-9900
Mailing Address - Street 1:577 ISHAM ST
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10034-2034
Mailing Address - Country:US
Mailing Address - Phone:212-942-9900
Mailing Address - Fax:212-942-2322
Practice Address - Street 1:577 ISHAM ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10034-2034
Practice Address - Country:US
Practice Address - Phone:212-942-9900
Practice Address - Fax:212-942-2322
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-27
Last Update Date:2008-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0453231223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01510269Medicaid