Provider Demographics
NPI:1063208502
Name:BROADWAY SMILE BOUTIQUE
Entity type:Organization
Organization Name:BROADWAY SMILE BOUTIQUE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:KARO
Authorized Official - Last Name:SHIRINIAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:818-454-6382
Mailing Address - Street 1:3331 CASTLEMAN LN
Mailing Address - Street 2:
Mailing Address - City:BURBANK
Mailing Address - State:CA
Mailing Address - Zip Code:91504-1630
Mailing Address - Country:US
Mailing Address - Phone:818-454-6382
Mailing Address - Fax:
Practice Address - Street 1:1100 E BROADWAY # 302
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91205-1384
Practice Address - Country:US
Practice Address - Phone:818-900-1100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-04-18
Last Update Date:2025-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental