Healthcare Provider Details

I. General information

NPI: 1083849178
Provider Name (Legal Business Name): PRASHANTI BOLLU D.M.D., M.S., M.B.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/19/2009
Last Update Date: 09/15/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4 SUNSET WAY STE C
HENDERSON NV
89014-2016
US

IV. Provider business mailing address

35 GLEN EDEN CT
HENDERSON NV
89074-6290
US

V. Phone/Fax

Practice location:
  • Phone: 702-968-5690
  • Fax:
Mailing address:
  • Phone: 617-849-0751
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberS3-228
License Number StateNV
# 2
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number5790
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: