Organization
BROADWAY DENTAL PSC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. RODNEY BRENT FULTZ DMD (SEC TREASURER)
(502) 772-7531
Entity
Organization
Contact information
Practice address
1813 WEST BROADWAY, LOUISVILLE, KY 40203
(502) 772-7531
Mailing address
1813 WEST BROADWAY, LOUISVILLE, KY 40203
(502) 772-7531
Taxonomy
Speciality
Code
Description
License number
State
122300000X
Dentist
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
61941878
—
KY
Enumeration date
01/18/2007
Last updated
12/18/2007
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