Healthcare Provider Details

I. General information

NPI: 1871650226
Provider Name (Legal Business Name): JASON T VANLUE DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/03/2007
Last Update Date: 04/27/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2811 N GREEN VALLEY PKWY
HENDERSON NV
89014-0401
US

IV. Provider business mailing address

2811 N GREEN VALLEY PKWY
HENDERSON NV
89014-0401
US

V. Phone/Fax

Practice location:
  • Phone: 702-434-2219
  • Fax:
Mailing address:
  • Phone: 702-434-2219
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberS3-219
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: