Healthcare Provider Details

I. General information

NPI: 1144331588
Provider Name (Legal Business Name): ED DEANDRADE DDS, LTD.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2610 W HORIZON RIDGE PKWY SUITE #202
HENDERSON NV
89052-2869
US

IV. Provider business mailing address

2610 W HORIZON RIDGE PKWY SUITE #202
HENDERSON NV
89052-2869
US

V. Phone/Fax

Practice location:
  • Phone: 702-270-4600
  • Fax: 702-270-7773
Mailing address:
  • Phone: 702-270-4600
  • Fax: 702-270-7773

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number3586
License Number StateNV

VIII. Authorized Official

Name: DR. ED DE ANDRADE
Title or Position: PRESIDENT
Credential: DDS
Phone: 702-270-4600