MEDICARE: RAINBOW DENTAL, 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	1223G0001X	General Practice Dentistry	4509	NV

General Provider Information

NPI Number	:	1528365897
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RAINBOW DENTAL, LLC

Provider Business Mailing Address
First Line	:	526 S TONOPAH DR
Second Line	:	SUITE 200
City	:	LAS VEGAS
State	:	NV
Zip	:	89106-4043
Country	:	US
Telephone Number	:	702-435-5015
Fax Number	:	702-366-1483

Provider Business Practice Location Address
First Line	:	7320 S RAINBOW BLVD
Second Line	:	SUITE 103
City	:	LAS VEGAS
State	:	NV
Zip	:	89139-0406
Country	:	US
Telephone Number	:	702-435-5015
Fax Number	:	702-366-1483

Authorized Official
Title or Position	:	OWNER
Name	:	BENNY KOHANTEB
Credential	:
Telephone Number	:	702-435-5015

Provider Enumeration Date	:	02/22/2011
Last Update Date	:	02/22/2011

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