MEDICARE: WOW 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

General Provider Information

NPI Number	:	1558052548
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WOW DENTAL LLC

Provider Business Mailing Address
First Line	:	PO BOX 70887
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44190-0887
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2050 E SERENE AVE
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89123-4820
Country	:	US
Telephone Number	:	877-681-0881
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	WHITNEY WHITE
Credential	:
Telephone Number	:	315-454-6000

Provider Enumeration Date	:	05/19/2023
Last Update Date	:	05/19/2023

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Directions to “WOW DENTAL LLC ” Practice Location

Language	Start Address	Practice Location

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