Provider Demographics
NPI:1114911617
Name:BROADWAY-FIRMAGE, VIVIAN MARIE (DDS)
Entity type:Individual
Prefix:DR
First Name:VIVIAN
Middle Name:MARIE
Last Name:BROADWAY-FIRMAGE
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:141 CAMINO ALTO
Mailing Address - Street 2:SUITE 2
Mailing Address - City:MILL VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:94941-2246
Mailing Address - Country:US
Mailing Address - Phone:415-388-6025
Mailing Address - Fax:415-388-1431
Practice Address - Street 1:141 CAMINO ALTO
Practice Address - Street 2:SUITE 2
Practice Address - City:MILL VALLEY
Practice Address - State:CA
Practice Address - Zip Code:94941-2246
Practice Address - Country:US
Practice Address - Phone:415-388-6025
Practice Address - Fax:415-388-1431
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA420331223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice