Provider Demographics
NPI:1457797318
Name:BROADWAY FAMILY DENTAL P.C.
Entity type:Organization
Organization Name:BROADWAY FAMILY DENTAL P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANDREY
Authorized Official - Middle Name:
Authorized Official - Last Name:IVANOV
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:7180-455-4400
Mailing Address - Street 1:1152 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11221-3002
Mailing Address - Country:US
Mailing Address - Phone:718-455-4400
Mailing Address - Fax:
Practice Address - Street 1:1152 BROADWAY
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11221-3002
Practice Address - Country:US
Practice Address - Phone:718-455-4400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-20
Last Update Date:2013-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental