MEDICARE: STEVEN DELISLE DDS P.C.

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	5929	NV

General Provider Information

NPI Number	:	1720495872
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	STEVEN DELISLE DDS P.C.

Provider Business Mailing Address
First Line	:	4080 N MLK BLVD STE 101B
Second Line	:
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89032-3217
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4080 N MLK BLVD STE 101B
Second Line	:
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89032-3217
Country	:	US
Telephone Number	:	425-306-2579
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	STEVEN DELISLE
Credential	:
Telephone Number	:	425-306-2579

Provider Enumeration Date	:	07/21/2014
Last Update Date	:	07/21/2014

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