MEDICARE: STEVEN DELISLE DDS PC

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	5929	NV

General Provider Information

NPI Number	:	1881106326
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	STEVEN DELISLE DDS PC

Provider Business Mailing Address
First Line	:	2480 E TOMPKINS AVE STE 102
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89121-5466
Country	:	US
Telephone Number	:	702-524-5732
Fax Number	:

Provider Business Practice Location Address
First Line	:	6415 S FORT APACHE RD STE 150
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89148-6749
Country	:	US
Telephone Number	:	702-710-0801
Fax Number	:

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

Provider Enumeration Date	:	10/24/2017
Last Update Date	:	10/24/2017

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