Healthcare Provider Details

I. General information

NPI: 1629133921
Provider Name (Legal Business Name): JALEH POURHAMIDI DMD, MDSC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/27/2006
Last Update Date: 08/23/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4 SUNSET WAY BUILDING C
HENDERSON NV
89014
US

IV. Provider business mailing address

11 SUNSET WAY
HENDERSON NV
89014
US

V. Phone/Fax

Practice location:
  • Phone: 702-968-1652
  • Fax: 702-990-4435
Mailing address:
  • Phone: 702-968-1652
  • Fax: 702-990-4435

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberLL002703
License Number StateNV
# 2
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberS3-88C
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: