Organization
BROADWAY DENTAL SERVICES
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. MUKUKA KAPILIKISHA DMD (OWNER)
(219) 671-3754
Entity
Organization
Contact information
Practice address
3195 BROADWAY, GARY, IN 46409-1006
(219) 671-3754
Mailing address
1693 STILLWATER AVE, DYER, IN 46311-3088
(219) 671-3754
Taxonomy
Speciality
Code
Description
License number
State
1223G0001X
General Practice Dentistry
Primary
12011216A
IN
Other
Enumeration date
09/16/2011
Last updated
09/16/2011
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