Healthcare Provider Details

I. General information

NPI: 1407541337
Provider Name (Legal Business Name): MODERN DENTAL SPECIALIST, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/06/2023
Last Update Date: 04/06/2023
Certification Date: 04/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4610 E SUNSET RD
HENDERSON NV
89014-2202
US

IV. Provider business mailing address

4618 MEADOWS LN
LAS VEGAS NV
89107-2956
US

V. Phone/Fax

Practice location:
  • Phone: 702-200-9000
  • Fax:
Mailing address:
  • Phone: 702-623-3200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State

VIII. Authorized Official

Name: BENNY KOHANTEB
Title or Position: DENTIST
Credential: DDS
Phone: 818-631-3368