Healthcare Provider Details

I. General information

NPI: 1265096630
Provider Name (Legal Business Name): CDE VENTURE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/30/2019
Last Update Date: 04/30/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2578 IDAHO ST
ELKO NV
89801-4601
US

IV. Provider business mailing address

6339 S VINECREST DR
SALT LAKE CITY UT
84121-2426
US

V. Phone/Fax

Practice location:
  • Phone: 775-299-4790
  • Fax: 775-738-0495
Mailing address:
  • Phone: 801-891-5520
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. BRIAN CRAIG ANDERSON
Title or Position: OWNER
Credential: DDS, MS
Phone: 801-891-5580