Healthcare Provider Details

I. General information

NPI: 1205372265
Provider Name (Legal Business Name): BROADWAY DENTAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/16/2017
Last Update Date: 01/16/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 S BROADWAY ST
CASSOPOLIS MI
49031-1243
US

IV. Provider business mailing address

PO BOX 8
CASSOPOLIS MI
49031-0008
US

V. Phone/Fax

Practice location:
  • Phone: 269-445-5550
  • Fax: 269-445-0101
Mailing address:
  • Phone: 269-445-5550
  • Fax: 269-445-0101

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number2915566
License Number StateMI

VIII. Authorized Official

Name: HEATHER MCINTYRE
Title or Position: FINANCIAL COORDINATOR
Credential:
Phone: 269-445-5550