| NPI | 1528103629 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | HEIDI A PROVOST Office Manager 702-304-1902 |
| Organization Subpart ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: NV 4845) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: NV 4801) |
| Enumeration Date | 2007-02-20 |
| Last Update Date | 2020-08-22 |