# ON BROADWAY DENTISTRY

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

## Provider details

- **NPI number:** 1851857064
- **Authorized official:** BENNETT MANKIN (CEO)
- **Authorized official phone:** (480) 636-0170

## Contact information

- **Practice address:** 4435 E BROADWAY RD \# 9, MESA, AZ 85206-2012
- **Practice address phone:** (480) 223-0255
- **Practice address fax:** (480) 654-0705
- **Mailing address:** 3658 E MORRISON RANCH PKWY, GILBERT, AZ 85296-1816
- **Mailing address phone:** (480) 636-0170

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 1223G0001X | General Practice Dentistry | — | NULL | Yes |
| 1223G0001X | General Practice Dentistry | — | — | Yes |
| 261QD0000X | Dental Clinic/Center | — | NULL | — |
| 332B00000X | Durable Medical Equipment & Medical Supplies | — | NULL | — |

## Other

- **Enumeration date:** 02/12/2019
- **Last updated:** 02/07/2020