MEDICARE: DR. ANGELICA JANE BUSTOS THACKER DMD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	7617	NV

General Provider Information

NPI Number	:	1073251963
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ANGELICA JANE BUSTOS THACKER DMD

Provider Business Mailing Address
First Line	:	12028 HATHAWAY PINES LN
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89138-4501
Country	:	US
Telephone Number	:	702-883-9376
Fax Number	:

Provider Business Practice Location Address
First Line	:	7603 GRAND TETON DR STE 140
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89131-1602
Country	:	US
Telephone Number	:	702-957-1013
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/22/2022
Last Update Date	:	03/17/2023

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