Provider Demographics
NPI:1053191437
Name:ISMILE DENTAL AT BROADWAY
Entity type:Organization
Organization Name:ISMILE DENTAL AT BROADWAY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:NGUYEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:214-790-1012
Mailing Address - Street 1:3209 LESTER DR
Mailing Address - Street 2:
Mailing Address - City:RICHARDSON
Mailing Address - State:TX
Mailing Address - Zip Code:75082-3771
Mailing Address - Country:US
Mailing Address - Phone:214-790-1012
Mailing Address - Fax:
Practice Address - Street 1:4449 BROADWAY BLVD
Practice Address - Street 2:
Practice Address - City:GARLAND
Practice Address - State:TX
Practice Address - Zip Code:75043-3435
Practice Address - Country:US
Practice Address - Phone:972-303-0105
Practice Address - Fax:972-303-0106
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-03
Last Update Date:2023-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty