Provider Demographics
NPI:1316082332
Name:BROADWAY DENTAL HEALTH BOUTIQUE,P.C.
Entity type:Organization
Organization Name:BROADWAY DENTAL HEALTH BOUTIQUE,P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRES
Authorized Official - Prefix:DR
Authorized Official - First Name:SAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:SCHWALB
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:718-218-8191
Mailing Address - Street 1:158 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11211-6193
Mailing Address - Country:US
Mailing Address - Phone:718-218-8191
Mailing Address - Fax:
Practice Address - Street 1:158 BROADWAY
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11211-6193
Practice Address - Country:US
Practice Address - Phone:718-218-8191
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0038195122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty