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Organization
ON BROADWAY DENTISTRY
Active
Organization
ON BROADWAY DENTISTRY
Active
Organization subpart
No
Provider details
NPI number
Authorized official
BENNETT MANKIN (CEO)
(480) 636-0170
Entity
Organization
Contact information
Practice address
4435 E BROADWAY RD # 9, MESA, AZ 85206-2012
(480) 223-0255
(480) 654-0705
Mailing address
3658 E MORRISON RANCH PKWY, GILBERT, AZ 85296-1816
(480) 636-0170
Taxonomy
Speciality
Code
Description
License number
State
1223G0001X
General Practice Dentistry
Primary
—
NULL
1223G0001X
General Practice Dentistry
Primary
—
—
261QD0000X
Dental Clinic/Center
—
NULL
332B00000X
Durable Medical Equipment & Medical Supplies
—
NULL
Other
Enumeration date
02/12/2019
Last updated
02/07/2020
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