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General NPI Number Information
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NPI Number | 1134493182
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Entity Type | Organization
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Legal Business Name | NEW BROADWAY DENTAL
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Dates
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Enumeration Date | 03/07/2012
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Last Update Date | 03/07/2012
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Provider Practice Location Address
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Address Line | 1501 BROADWAY
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City | NEW YORK
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State | NY
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Zip | 10036-5601
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Country | US
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Telephone | 212-398-1969
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Fax | 212-398-1971
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Provider Business Mailing Address
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Address Line | 1501 BROADWAY
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City | NEW YORK
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State | NY
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Zip | 10036-5601
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Country | US
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Telephone | 212-398-1969
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Fax | 212-398-1971
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Authorized Official
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Title or Position | DDS
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Name | NATALYA MODLIN
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Credential |
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Telephone | 201-873-9898
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 050515
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License Number State | NY
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