Healthcare Provider Details

I. General information

NPI: 1265910970
Provider Name (Legal Business Name): MARVEL DENTAL CARSON CITY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/03/2018
Last Update Date: 11/21/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

410 FLEISCHMANN WAY SUITE A.
CARSON CITY NV
89703
US

IV. Provider business mailing address

410 FLEISCHMANN WAY SUITE A.
CARSON CITY NV
89703
US

V. Phone/Fax

Practice location:
  • Phone: 775-884-3322
  • Fax: 775-884-4432
Mailing address:
  • Phone: 775-884-3322
  • Fax: 775-884-4432

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number4821
License Number StateNV

VIII. Authorized Official

Name: ANGELA K. GOLDEN
Title or Position: CONSULTANT
Credential:
Phone: 775-884-3322