Healthcare Provider Details

I. General information

NPI: 1851857064
Provider Name (Legal Business Name): ON BROADWAY DENTISTRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/12/2019
Last Update Date: 02/07/2020
Certification Date: 02/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4435 E BROADWAY RD # 9
MESA AZ
85206-2012
US

IV. Provider business mailing address

3658 E MORRISON RANCH PKWY
GILBERT AZ
85296-1816
US

V. Phone/Fax

Practice location:
  • Phone: 480-223-0255
  • Fax: 480-654-0705
Mailing address:
  • Phone: 480-636-0170
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: BENNETT MANKIN
Title or Position: CEO
Credential:
Phone: 480-636-0170