MEDICARE: GREATER LAS VEGAS

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	1223P0700X	Prosthodontics	S5 24	NV

General Provider Information

NPI Number	:	1457726960
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GREATER LAS VEGAS

Provider Business Mailing Address
First Line	:	8867 W. FLAMINGO RD.
Second Line	:	SUITE 100
City	:	LAS VEGAS
State	:	NV
Zip	:	89147
Country	:	US
Telephone Number	:	702-880-5858
Fax Number	:

Provider Business Practice Location Address
First Line	:	8867 W FLAMINGO RD
Second Line	:	SUITE 100
City	:	LAS VEGAS
State	:	NV
Zip	:	89147-8758
Country	:	US
Telephone Number	:	702-880-5858
Fax Number	:

Authorized Official
Title or Position	:	OFFICE ADMINISTRATOR
Name	:	MRS. GRACE O MARQUEZ
Credential	:
Telephone Number	:	702-880-5858

Provider Enumeration Date	:	12/09/2015
Last Update Date	:	12/09/2015

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Directions to “GREATER LAS VEGAS ” Practice Location

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