Healthcare Provider Details

I. General information

NPI: 1417041146
Provider Name (Legal Business Name): ELLSWORTH COX PEDIATRIC DENTISTRY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 11/12/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2843 SAINT ROSE PKWY #100
HENDERSON NV
89052-4813
US

IV. Provider business mailing address

2843 SAINT ROSE PKWY #100
HENDERSON NV
89052-4813
US

V. Phone/Fax

Practice location:
  • Phone: 702-531-5437
  • Fax: 702-616-3565
Mailing address:
  • Phone: 702-531-5437
  • Fax: 702-616-3565

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number3696
License Number StateNV
# 2
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number4341
License Number StateNV

VIII. Authorized Official

Name: MRS. DIANA B. MENDOZA
Title or Position: OFFICE MANAGER
Credential:
Phone: 702-459-5437