1043725039 NPI number — NORTHERN NEVADA DENTAL SPECIALTIES GROUP, LLC

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 1043725039 NPI number — NORTHERN NEVADA DENTAL SPECIALTIES GROUP, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTHERN NEVADA DENTAL SPECIALTIES GROUP, LLC
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:
6
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:
1043725039
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/12/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3605 GRANT DR
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:
89509-5301
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
775-409-4614
Provider Business Mailing Address Fax Number:
775-376-9075

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5030 LAS BRISAS BLVD STE B-3
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:
89523-6239
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:
12/12/2017

Additional Information

Authorized Official

Authorized Official Last Name:
BEUTER
Authorized Official First Name:
ALETA
Authorized Official Middle Name:
VALERIE
Authorized Official Title or Position:
CREDENTIALING SPECIALIST
Authorized Official Telephone Number:
775-409-4614

Provider Taxonomy Codes

  • Taxonomy code: 1223P0221X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1223P0221X . This is a "PEDIATRIC DENTISTRY" identifier . This identifiers is of the category "OTHER".




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