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General NPI Number Information
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NPI Number | 1275999872
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Entity Type | Organization
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Legal Business Name | BROADWAY SMILES
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Dates
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Enumeration Date | 01/12/2016
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Last Update Date | 01/12/2016
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Provider Practice Location Address
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Address Line | 505 1ST ST STE B
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City | IDAHO FALLS
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State | ID
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Zip | 83401-3929
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Country | US
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Telephone | 208-529-1903
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Fax | 208-529-1925
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Provider Business Mailing Address
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Address Line | 505 1ST ST STE B
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City | IDAHO FALLS
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State | ID
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Zip | 83401-3929
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Country | US
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Telephone | 208-529-1903
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Fax | 208-529-1925
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | NATALY PENUELAS
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Credential |
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Telephone | 208-680-0186
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number | D-4109
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License Number State | ID
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