Provider Demographics
NPI:1831839455
Name:BROADMOOR SRG PLLC
Entity type:Organization
Organization Name:BROADMOOR SRG PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:NINA
Authorized Official - Middle Name:
Authorized Official - Last Name:ABTAHI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:214-493-1216
Mailing Address - Street 1:500 N GALLOWAY AVE STE 6
Mailing Address - Street 2:
Mailing Address - City:MESQUITE
Mailing Address - State:TX
Mailing Address - Zip Code:75149-4338
Mailing Address - Country:US
Mailing Address - Phone:214-493-1216
Mailing Address - Fax:
Practice Address - Street 1:500 N GALLOWAY AVE STE 6
Practice Address - Street 2:
Practice Address - City:MESQUITE
Practice Address - State:TX
Practice Address - Zip Code:75149-4338
Practice Address - Country:US
Practice Address - Phone:214-493-1216
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-03-31
Last Update Date:2022-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty