MEDICARE: OPEN AIRWAY LAS VEGAS LLC

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	122300000X	Dentist
2	332BC3200X	Customized Equipment (DME)

General Provider Information

NPI Number	:	1104432939
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OPEN AIRWAY LAS VEGAS LLC

Provider Business Mailing Address
First Line	:	8845 HELENA AVE
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89129-3631
Country	:	US
Telephone Number	:	702-756-8422
Fax Number	:

Provider Business Practice Location Address
First Line	:	7180 CASCADE VALLEY CT STE 100
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89128-1407
Country	:	US
Telephone Number	:	702-756-8422
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. BLAIR A. ISOM
Credential	:	DDS
Telephone Number	:	702-756-8422

Provider Enumeration Date	:	09/17/2020
Last Update Date	:	09/17/2020

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Directions to “OPEN AIRWAY LAS VEGAS LLC ” Practice Location

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