Organization
BROADWAY DENTAL CENTER, LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
GURAM YAKOBASHVILI DDS (OWNER)
(973) 777-1202
Entity
Organization
Contact information
Practice address
15 BROADWAY, PASSAIC, NJ 07055-5007
(973) 777-1202
(973) 777-0159
Mailing address
15 BROADWAY, PASSAIC, NJ 07055-5007
(973) 777-1202
(973) 777-0159
Taxonomy
Speciality
Code
Description
License number
State
1223G0001X
General Practice Dentistry
Primary
20280
NJ
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
8444706
—
NJ
Enumeration date
04/10/2007
Last updated
08/22/2020
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