| Broadway Dental Center | |
|
208 E Broadway Ave Montesano WA 98563-3706 | |
| (360) 249-3151 | |
| (360) 249-5129 |
| Full Name | Broadway Dental Center |
|---|---|
| Speciality | Dentist |
| Location | 208 E Broadway Ave, Montesano, Washington |
| Authorized Official Name and Position | Russell M Larsen (CO-OWNER) |
| Authorized Official Contact | 3602493151 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
| Broadway Dental Center 208 E Broadway Ave Montesano WA 98563-3706 Ph: (360) 249-3151 | Broadway Dental Center 208 E Broadway Ave Montesano WA 98563-3706 Ph: (360) 249-3151 |
| NPI Number | 1619073061 |
|---|---|
| Provider Enumeration Date | 09/15/2006 |
| Last Update Date | 08/22/2020 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1619073061 | NPI | - | NPPES |
| 5306808 | Medicaid | WA |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 122300000X | Dentist | DE00008166 (Washington) | Primary |
| 122300000X | Dentist | DE00007407 (Washington) | Secondary |
Broadway Dental Dental Clinic Medicare: Not Enrolled in Medicare Practice Location: 208 E. Broadway, Montesano, WA 98563 Phone: 360-249-3151 Fax: 360-249-5129 |