Healthcare Provider Details

I. General information

NPI: 1326537028
Provider Name (Legal Business Name): HENDERSON PEDIATRIC DENTISTRY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/08/2018
Last Update Date: 05/08/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

390 N STEPHANIE ST STE 104
HENDERSON NV
89014-8029
US

IV. Provider business mailing address

390 N STEPHANIE ST STE 104
HENDERSON NV
89014-8029
US

V. Phone/Fax

Practice location:
  • Phone: 720-603-4700
  • Fax:
Mailing address:
  • Phone:
  • 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: DIANE STACEY
Title or Position: DR
Credential:
Phone: 303-603-4800