MEDICARE: SOUTHERN NEVADA ORTHODONTICS, 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	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry

General Provider Information

NPI Number	:	1407312754
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHERN NEVADA ORTHODONTICS, LLC

Provider Business Mailing Address
First Line	:	6870 S RAINBOW BLVD STE 112
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89118-2108
Country	:	US
Telephone Number	:	702-909-2900
Fax Number	:

Provider Business Practice Location Address
First Line	:	6870 S RAINBOW BLVD STE 112
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89118-2108
Country	:	US
Telephone Number	:	702-909-2900
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. BYRON H TAM
Credential	:	DDS
Telephone Number	:	702-909-2900

Provider Enumeration Date	:	02/12/2019
Last Update Date	:	02/12/2019

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