MEDICARE: BROADWAY PEDIATRIC DENTISTRY, PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223P0221X	Pediatric Dentistry

General Provider Information

NPI Number	:	1962159400
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BROADWAY PEDIATRIC DENTISTRY, PLLC

Provider Business Mailing Address
First Line	:	PO BOX 356
Second Line	:
City	:	LYTLE
State	:	TX
Zip	:	78052-0356
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3006 BROADWAY STE 103
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78209-1561
Country	:	US
Telephone Number	:	210-225-8888
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	JOANNA AYALA
Credential	:
Telephone Number	:	121-063-2456

Provider Enumeration Date	:	03/04/2022
Last Update Date	:	03/04/2022

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