MEDICARE: RADIANT SMILES

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	6837	NV

General Provider Information

NPI Number	:	1417408477
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RADIANT SMILES

Provider Business Mailing Address
First Line	:	1825 S NELLIS BLVD
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89104-6215
Country	:	US
Telephone Number	:	702-432-0199
Fax Number	:

Provider Business Practice Location Address
First Line	:	1825 S NELLIS BLVD
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89104-6215
Country	:	US
Telephone Number	:	702-432-0199
Fax Number	:

Authorized Official
Title or Position	:	OWNER DENTIST
Name	:	ADRIAN RUIZ
Credential	:	DDS
Telephone Number	:	702-432-0199

Provider Enumeration Date	:	10/14/2016
Last Update Date	:	10/14/2016

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Directions to “RADIANT SMILES ” Practice Location

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