Healthcare Provider Details

I. General information

NPI: 1578570578
Provider Name (Legal Business Name): DODGE ALAN SLAGLE DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/02/2006
Last Update Date: 06/18/2021
Certification Date: 06/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1070 WIGWAM PARKWAY #100
HENDERSON NV
89074
US

IV. Provider business mailing address

1070 WIGWAM PARKWAY #100
HENDERSON NV
89074
US

V. Phone/Fax

Practice location:
  • Phone: 702-454-0201
  • Fax: 702-454-1245
Mailing address:
  • Phone: 702-454-0201
  • Fax: 702-454-1245

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number500
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: