Healthcare Provider Details

I. General information

NPI: 1073042446
Provider Name (Legal Business Name): WANNI LIE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/08/2017
Last Update Date: 06/08/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10870 W CHARLESTON BLVD STE 170
LAS VEGAS NV
89135-1170
US

IV. Provider business mailing address

1504 TRUETT ST UNIT 101
LAS VEGAS NV
89128-8074
US

V. Phone/Fax

Practice location:
  • Phone: 702-254-6412
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number6920
License Number StateNV
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number6920
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: