Provider Demographics
NPI:1790816817
Name:BROADWAY DENTAL LLC
Entity Type:Organization
Organization Name:BROADWAY DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:E
Authorized Official - Last Name:BYGNESS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:712-263-5615
Mailing Address - Street 1:1415 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:DENISON
Mailing Address - State:IA
Mailing Address - Zip Code:51442-2052
Mailing Address - Country:US
Mailing Address - Phone:712-263-5615
Mailing Address - Fax:712-263-8124
Practice Address - Street 1:1415 BROADWAY
Practice Address - Street 2:
Practice Address - City:DENISON
Practice Address - State:IA
Practice Address - Zip Code:51442-2052
Practice Address - Country:US
Practice Address - Phone:712-263-5615
Practice Address - Fax:712-263-8124
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA079121223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty