MEDICARE: MADDISON AVE DENTAL

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

General Provider Information

NPI Number	:	1316963861
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MADDISON AVE DENTAL

Provider Business Mailing Address
First Line	:	4358 W CHEYENNE AVE
Second Line	:
City	:	N LAS VEGAS
State	:	NV
Zip	:	89032-2484
Country	:	US
Telephone Number	:	702-735-9500
Fax Number	:	702-693-6500

Provider Business Practice Location Address
First Line	:	4358 W CHEYENNE AVE
Second Line	:
City	:	N LAS VEGAS
State	:	NV
Zip	:	89032-2484
Country	:	US
Telephone Number	:	702-735-9500
Fax Number	:	702-693-6500

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	AMIE LEAVITT
Credential	:
Telephone Number	:	702-735-9500

Provider Enumeration Date	:	07/15/2006
Last Update Date	:	08/22/2020

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Directions to “MADDISON AVE DENTAL ” Practice Location

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