Provider Demographics
NPI:1922378900
Name:BROADWAY FAMILY DENTAL CENTER
Entity Type:Organization
Organization Name:BROADWAY FAMILY DENTAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:J
Authorized Official - Last Name:PULLARA
Authorized Official - Suffix:JR
Authorized Official - Credentials:DDS
Authorized Official - Phone:815-634-8009
Mailing Address - Street 1:595 N BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:COAL CITY
Mailing Address - State:IL
Mailing Address - Zip Code:60416-1046
Mailing Address - Country:US
Mailing Address - Phone:815-634-8009
Mailing Address - Fax:815-634-2008
Practice Address - Street 1:595 N BROADWAY ST
Practice Address - Street 2:
Practice Address - City:COAL CITY
Practice Address - State:IL
Practice Address - Zip Code:60416-1046
Practice Address - Country:US
Practice Address - Phone:815-634-8009
Practice Address - Fax:815-634-2008
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-06
Last Update Date:2012-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190214931223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty