Healthcare Provider Details

I. General information

NPI: 1043888936
Provider Name (Legal Business Name): CORONADO CANYON DENTISTREE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/16/2021
Last Update Date: 06/06/2023
Certification Date: 06/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

660 S GREEN VALLEY PKWY STE 110
HENDERSON NV
89052-0431
US

IV. Provider business mailing address

660 S GREEN VALLEY PKWY STE 110
HENDERSON NV
89052-0431
US

V. Phone/Fax

Practice location:
  • Phone: 702-610-8734
  • Fax:
Mailing address:
  • Phone: 702-610-8734
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number StateNULL

VIII. Authorized Official

Name: ELEAZAR SANTIAGO
Title or Position: DOCTOR
Credential:
Phone: 702-610-8734