Provider Demographics
NPI:1730675273
Name:ASTORIA DENTAL BROADWAY
Entity Type:Organization
Organization Name:ASTORIA DENTAL BROADWAY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:
Authorized Official - Last Name:MARON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:929-522-0554
Mailing Address - Street 1:31-72 31ST ST
Mailing Address - Street 2:SUITE #1
Mailing Address - City:ASTORIA
Mailing Address - State:NY
Mailing Address - Zip Code:11106
Mailing Address - Country:US
Mailing Address - Phone:929-522-0554
Mailing Address - Fax:
Practice Address - Street 1:31-72 31ST ST
Practice Address - Street 2:SUITE #1
Practice Address - City:ASTORIA
Practice Address - State:NY
Practice Address - Zip Code:11106
Practice Address - Country:US
Practice Address - Phone:929-522-0554
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-09
Last Update Date:2018-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0436411223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1215035134OtherTYPE 2