Provider Demographics
NPI:1639642028
Name:BROADWAY DENTAL GROUP, PC
Entity Type:Organization
Organization Name:BROADWAY DENTAL GROUP, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:LENA
Authorized Official - Middle Name:
Authorized Official - Last Name:KHAYLOMSKY
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:862-237-7810
Mailing Address - Street 1:81 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07104-3801
Mailing Address - Country:US
Mailing Address - Phone:862-237-7810
Mailing Address - Fax:862-237-7807
Practice Address - Street 1:81 BROADWAY
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07104-3801
Practice Address - Country:US
Practice Address - Phone:862-237-7810
Practice Address - Fax:862-237-7807
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-08
Last Update Date:2019-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental