Provider Demographics
NPI:1063134708
Name:BROADWAY DENTAL PC
Entity type:Organization
Organization Name:BROADWAY DENTAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:REBEKAH
Authorized Official - Middle Name:K
Authorized Official - Last Name:BLANCHETTE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:207-945-5300
Mailing Address - Street 1:743 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04401-3225
Mailing Address - Country:US
Mailing Address - Phone:207-945-5300
Mailing Address - Fax:
Practice Address - Street 1:743 BROADWAY
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-3225
Practice Address - Country:US
Practice Address - Phone:207-945-5300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-09-19
Last Update Date:2022-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME1871684282Other1-IND
ME1679142988Other1-IND
ME1740591882Other1-IND