Healthcare Provider Details

I. General information

NPI: 1437238607
Provider Name (Legal Business Name): BROADWAY GENTLE DENTISTRY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/06/2006
Last Update Date: 10/06/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2302 S DIXON RD STE 125
KOKOMO IN
46902-6425
US

IV. Provider business mailing address

2302 S DIXON RD STE 125
KOKOMO IN
46902-6425
US

V. Phone/Fax

Practice location:
  • Phone: 765-453-9389
  • Fax: 765-453-9369
Mailing address:
  • Phone: 765-453-9389
  • Fax: 765-453-9369

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number54001486A
License Number StateIN

VIII. Authorized Official

Name: EDWARD T MAMARIL
Title or Position: PRESIDENT
Credential: DDS
Phone: 765-453-9389