1336310309 NPI number — DR. RONALD L LEBROKE DMD

Table of content: DR. RONALD L LEBROKE DMD (NPI 1336310309)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336310309 NPI number — DR. RONALD L LEBROKE DMD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LEBROKE
Provider First Name:
RONALD
Provider Middle Name:
L
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DMD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
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:
1336310309
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/20/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
526 S TONOPAH DR
Provider Second Line Business Mailing Address:
SUITE #200
Provider Business Mailing Address City Name:
LAS VEGAS
Provider Business Mailing Address State Name:
NV
Provider Business Mailing Address Postal Code:
89106-4043
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
702-291-2031
Provider Business Mailing Address Fax Number:
702-366-1483

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4720 BLUE DIAMOND RD
Provider Second Line Business Practice Location Address:
#100
Provider Business Practice Location Address City Name:
LAS VEGAS
Provider Business Practice Location Address State Name:
NV
Provider Business Practice Location Address Postal Code:
89139-7661
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
702-855-0050
Provider Business Practice Location Address Fax Number:
702-629-2410
Provider Enumeration Date:
03/18/2008

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  5606 , registered in the state of NV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 1223G0001X , with the licence number: 57069 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 1336310309 , issued by the state of ( NV ) . This identifiers is of the category "MEDICAID".




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