MEDICARE: GO KIDS DENTAL NORTH DECATUR, LLC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	1223G0001X	General Practice Dentistry
2	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry
3	1223P0221X	Pediatric Dentistry

General Provider Information

NPI Number	:	1184450405
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GO KIDS DENTAL NORTH DECATUR, LLC

Provider Business Mailing Address
First Line	:	6311 N DECATUR BLVD STE 140
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89130-8013
Country	:	US
Telephone Number	:	702-522-0119
Fax Number	:

Provider Business Practice Location Address
First Line	:	6311 N DECATUR BLVD STE 140
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89130-8013
Country	:	US
Telephone Number	:	702-522-0119
Fax Number	:

Authorized Official
Title or Position	:	DENTIST
Name	:	DEEP KARAN DHILLON
Credential	:
Telephone Number	:	702-522-0119

Provider Enumeration Date	:	09/12/2024
Last Update Date	:	09/12/2024

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