MEDICARE: SUMMER LANE

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	122300000X	Dentist	DS-041228	PA
2	1223S0112X	Oral and Maxillofacial Surgery (Dentist)	S2-180	NV

General Provider Information

NPI Number	:	1558761585
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUMMER LANE

Provider Business Mailing Address
First Line	:	7221 HARLOW ST
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89131-2332
Country	:	US
Telephone Number	:	415-990-1052
Fax Number	:

Provider Business Practice Location Address
First Line	:	6780 S FORT APACHE RD STE 108
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89148-5405
Country	:	US
Telephone Number	:	725-235-9301
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/27/2014
Last Update Date	:	06/10/2022

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Directions to “ SUMMER LANE ” Practice Location

Language	Start Address	Practice Location

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