Provider Demographics
NPI:1790955235
Name:BROADWAY DENATL CARE, PC
Entity Type:Organization
Organization Name:BROADWAY DENATL CARE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:THAI
Authorized Official - Middle Name:G
Authorized Official - Last Name:LUONG
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:212-226-6262
Mailing Address - Street 1:401 BROADWAY STE 206
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10013-3033
Mailing Address - Country:US
Mailing Address - Phone:212-226-6262
Mailing Address - Fax:212-226-4663
Practice Address - Street 1:401 BROADWAY STE 206
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10013-3033
Practice Address - Country:US
Practice Address - Phone:212-226-6262
Practice Address - Fax:212-226-4663
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-11
Last Update Date:2008-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY047394122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty