Provider Demographics
NPI:1356622435
Name:BROADWAY DENTAL LLC
Entity type:Organization
Organization Name:BROADWAY DENTAL LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TAROLL
Authorized Official - Middle Name:A
Authorized Official - Last Name:GRAZIANO
Authorized Official - Suffix:
Authorized Official - Credentials:BS
Authorized Official - Phone:623-556-7789
Mailing Address - Street 1:3414 W. UNION HILLS DR
Mailing Address - Street 2:UNIT 8
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85027
Mailing Address - Country:US
Mailing Address - Phone:480-664-2244
Mailing Address - Fax:623-236-9360
Practice Address - Street 1:55 E. BROADWAY
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85282
Practice Address - Country:US
Practice Address - Phone:480-664-2244
Practice Address - Fax:623-236-9360
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-02
Last Update Date:2011-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD7840122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
No122300000XDental ProvidersDentistGroup - Single Specialty