Provider Demographics
NPI:1740901867
Name:BROADWAY DENTAL GROUP PLLC
Entity type:Organization
Organization Name:BROADWAY DENTAL GROUP PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:FARAJOLLAH
Authorized Official - Middle Name:
Authorized Official - Last Name:SOLEIMANZADEH
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:516-476-4509
Mailing Address - Street 1:15 WOODFIELD LN
Mailing Address - Street 2:
Mailing Address - City:GLEN HEAD
Mailing Address - State:NY
Mailing Address - Zip Code:11545-2242
Mailing Address - Country:US
Mailing Address - Phone:516-476-4509
Mailing Address - Fax:
Practice Address - Street 1:7410 BROADWAY
Practice Address - Street 2:
Practice Address - City:ELMHURST
Practice Address - State:NY
Practice Address - Zip Code:11373-5609
Practice Address - Country:US
Practice Address - Phone:516-476-4509
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-09-07
Last Update Date:2022-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No1223E0200XDental ProvidersDentistEndodonticsGroup - Multi-Specialty
No1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
No1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty
No1223P0700XDental ProvidersDentistProsthodonticsGroup - Multi-Specialty
No1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty
No124Q00000XDental ProvidersDental HygienistGroup - Multi-Specialty