# BROADWAY DENTAL SERVICES

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1215219084
- **Authorized official:** DR. MUKUKA KAPILIKISHA DMD (OWNER)
- **Authorized official phone:** (219) 671-3754

## Contact information

- **Practice address:** 3195 BROADWAY, GARY, IN 46409-1006
- **Practice address phone:** (219) 671-3754
- **Mailing address:** 1693 STILLWATER AVE, DYER, IN 46311-3088
- **Mailing address phone:** (219) 671-3754

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 1223G0001X | General Practice Dentistry | 12011216A | IN | Yes |

## Other

- **Enumeration date:** 09/16/2011
- **Last updated:** 09/16/2011