=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043520349
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BROADWAY DENTAL ASSOCIATES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/20/2010
-----------------------------------------------------
Last Update Date | 10/20/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 815 W BROAD ST SUITE A
-----------------------------------------------------
City | FALLS CHURCH
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22046-3107
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-533-8668
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 815 W BROAD ST SUITE A
-----------------------------------------------------
City | FALLS CHURCH
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22046-3107
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-533-8668
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PARTNERSHIP OWNER
-----------------------------------------------------
Name | MAQSOOD A CHAUDHRY
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 703-533-8668
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 0401412035
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 0401412386
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 0401007713
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------