Healthcare Provider Details

I. General information

NPI: 1790235315
Provider Name (Legal Business Name): BROADWAY FAMILY DENTAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/06/2016
Last Update Date: 10/10/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15 BROADWAY
PASSAIC NJ
07055-5007
US

IV. Provider business mailing address

15 BROADWAY
PASSAIC NJ
07055-5007
US

V. Phone/Fax

Practice location:
  • Phone: 973-955-2002
  • Fax:
Mailing address:
  • Phone: 973-955-2002
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number22DI020689
License Number StateNJ
# 4
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number
License Number State

VIII. Authorized Official

Name: DR. PRIYA DUGGAL
Title or Position: PERIODONTIST
Credential: DMD
Phone: 973-955-2022