Provider Demographics
NPI:1710703541
Name:BROADWAY ORAL SURGERY, LLC
Entity type:Organization
Organization Name:BROADWAY ORAL SURGERY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:SKOLNICK
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:908-469-9100
Mailing Address - Street 1:65 JEFFERSON AVE
Mailing Address - Street 2:FLOOR 2 SUITE A
Mailing Address - City:ELIZABETH
Mailing Address - State:NJ
Mailing Address - Zip Code:07201
Mailing Address - Country:US
Mailing Address - Phone:908-677-5040
Mailing Address - Fax:
Practice Address - Street 1:65 JEFFERSON AVE
Practice Address - Street 2:FLOOR 2 SUITE A
Practice Address - City:ELIZABETH
Practice Address - State:NJ
Practice Address - Zip Code:07201
Practice Address - Country:US
Practice Address - Phone:908-677-5040
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-11-26
Last Update Date:2024-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
No1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty