1093919458 NPI number — MOSAIC DENTAL, PROF. CORP.

Table of content: (NPI 1093919458)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093919458 NPI number — MOSAIC DENTAL, PROF. CORP.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MOSAIC DENTAL, PROF. CORP.
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:
MOSAIC DENTAL
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:
1093919458
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9690 W. TROPICANA AVE.
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAS VEGAS
Provider Business Mailing Address State Name:
NV
Provider Business Mailing Address Postal Code:
89147
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
702-433-8400
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
STAR BRITE DENTAL
Provider Second Line Business Practice Location Address:
893 S. RAINBOW BLVD.
Provider Business Practice Location Address City Name:
LAS VEGAS
Provider Business Practice Location Address State Name:
NV
Provider Business Practice Location Address Postal Code:
89145
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
702-456-0034
Provider Business Practice Location Address Fax Number:
702-856-0035
Provider Enumeration Date:
06/12/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
XA
Authorized Official First Name:
HAI
Authorized Official Middle Name:
Q.
Authorized Official Title or Position:
DOCTOR
Authorized Official Telephone Number:
702-456-0034

Provider Taxonomy Codes

  • Taxonomy code: 305R00000X , with the licence number:  3780 , 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)