Healthcare Provider Details

I. General information

NPI: 1255303723
Provider Name (Legal Business Name): MARC C VAN TASSELL D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 02/07/2006
Last Update Date: 04/11/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1304 E AULTMAN ST
ELY NV
89301-2513
US

IV. Provider business mailing address

1304 E AULTMAN ST
ELY NV
89301-2513
US

V. Phone/Fax

Practice location:
  • Phone: 775-289-6166
  • Fax:
Mailing address:
  • Phone: 775-289-6166
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number4743125-9922
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: