Healthcare Provider Details

I. General information

NPI: 1104768381
Provider Name (Legal Business Name): BROADWAY ORAL SURGERY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/07/2026
Last Update Date: 04/30/2026
Certification Date: 04/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

370 BROADWAY 3RD FLOOR SUITE 300
PATERSON NJ
07501
US

IV. Provider business mailing address

370 BROADWAY 3RD FLOOR SUITE 300
PATERSON NJ
07501
US

V. Phone/Fax

Practice location:
  • Phone: 973-221-8758
  • Fax:
Mailing address:
  • Phone: 973-221-8758
  • 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