Healthcare Provider Details

I. General information

NPI: 1710703541
Provider Name (Legal Business Name): BROADWAY ORAL SURGERY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/26/2024
Last Update Date: 11/26/2024
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

65 JEFFERSON AVE FLOOR 2 SUITE A
ELIZABETH NJ
07201
US

IV. Provider business mailing address

65 JEFFERSON AVE FLOOR 2 SUITE A
ELIZABETH NJ
07201
US

V. Phone/Fax

Practice location:
  • Phone: 908-677-5040
  • Fax:
Mailing address:
  • Phone: 908-677-5040
  • 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 Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State

VIII. Authorized Official

Name: MR. MICHAEL SKOLNICK
Title or Position: OWNER
Credential: DMD
Phone: 908-469-9100