MEDICARE: ABSOLUTE DENTAL MEADOWS, 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	:	1720380439
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ABSOLUTE DENTAL MEADOWS, LLC

Provider Business Mailing Address
First Line	:	526 S TONOPAH DR STE 200
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89106-4013
Country	:	US
Telephone Number	:	702-435-5015
Fax Number	:	702-366-1483

Provider Business Practice Location Address
First Line	:	4300 MEADOWS LN
Second Line	:	#1350
City	:	LAS VEGAS
State	:	NV
Zip	:	89107-3004
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	:	12/01/2010
Last Update Date	:	12/01/2010

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