1720346117 NPI number — NORTHERN NEVADA DENTAL SPECIALTIES GROUP

Table of content: (NPI 1720346117)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720346117 NPI number — NORTHERN NEVADA DENTAL SPECIALTIES GROUP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTHERN NEVADA DENTAL SPECIALTIES GROUP
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
MY KID'S SMILE
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1720346117
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/05/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10645 DOUBLE R BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RENO
Provider Business Mailing Address State Name:
NV
Provider Business Mailing Address Postal Code:
89521-8920
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
775-852-6164
Provider Business Mailing Address Fax Number:
775-284-7352

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10645 DOUBLE R BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RENO
Provider Business Practice Location Address State Name:
NV
Provider Business Practice Location Address Postal Code:
89521-8920
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
775-852-6164
Provider Business Practice Location Address Fax Number:
775-284-7352
Provider Enumeration Date:
04/24/2012

Additional Information

Authorized Official

Authorized Official Last Name:
WILKERSON
Authorized Official First Name:
J
Authorized Official Middle Name:
JUSTIN
Authorized Official Title or Position:
MANAGER
Authorized Official Telephone Number:
775-823-9797

Provider Taxonomy Codes

  • Taxonomy code: 1223P0221X , with the licence number:  S6-20 , registered in the state of NV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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