1649760257 NPI number — SORENSON PEDIATRIC DENTISTRY PLLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649760257 NPI number — SORENSON PEDIATRIC DENTISTRY PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SORENSON PEDIATRIC DENTISTRY PLLC
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:
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:
1649760257
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/18/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5745 S FORT APACHE RD STE 100
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:
89148-5623
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
702-586-4347
Provider Business Mailing Address Fax Number:
702-586-4847

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5745 S FORT APACHE RD STE 100
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAS VEGAS
Provider Business Practice Location Address State Name:
NV
Provider Business Practice Location Address Postal Code:
89148-5623
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
702-586-4347
Provider Business Practice Location Address Fax Number:
702-586-4847
Provider Enumeration Date:
05/18/2018

Additional Information

Authorized Official

Authorized Official Last Name:
SORENSON
Authorized Official First Name:
LEVI
Authorized Official Middle Name:
JOHN
Authorized Official Title or Position:
PEDIATRIC DENTIST
Authorized Official Telephone Number:
702-854-0005

Provider Taxonomy Codes

  • Taxonomy code: 1223P0221X , with the licence number:  S6-131 , 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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