Provider Demographics
NPI:1366733644
Name:BROADWAY FAMILY AND COSMETIC DENTISTRY PSC
Entity type:Organization
Organization Name:BROADWAY FAMILY AND COSMETIC DENTISTRY PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:APRILLE
Authorized Official - Middle Name:RASHEDA
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:859-253-3242
Mailing Address - Street 1:556 N BROADWAY
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40508-1761
Mailing Address - Country:US
Mailing Address - Phone:859-253-3242
Mailing Address - Fax:859-253-0025
Practice Address - Street 1:556 N BROADWAY
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40508-1761
Practice Address - Country:US
Practice Address - Phone:859-253-3242
Practice Address - Fax:859-253-0025
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-21
Last Update Date:2011-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY87311223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100149080Medicaid