MEDICARE: DENTAL NATION

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	305S00000X	Point of Service

General Provider Information

NPI Number	:	1447576665
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DENTAL NATION

Provider Business Mailing Address
First Line	:	1500 E DESERT INN RD
Second Line	:	STE #3
City	:	LAS VEGAS
State	:	NV
Zip	:	89169-2550
Country	:	US
Telephone Number	:	702-642-8101
Fax Number	:	702-642-1131

Provider Business Practice Location Address
First Line	:	1500 E DESERT INN RD
Second Line	:	STE #3
City	:	LAS VEGAS
State	:	NV
Zip	:	89169-2550
Country	:	US
Telephone Number	:	702-642-8101
Fax Number	:	702-642-1131

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. KLINE C BLACK
Credential	:	DMD
Telephone Number	:	702-642-8101

Provider Enumeration Date	:	04/13/2010
Last Update Date	:	12/16/2010

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Directions to “DENTAL NATION ” Practice Location

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