Healthcare Provider Details

I. General information

NPI: 1215615091
Provider Name (Legal Business Name): ANDREI DZEKOLA DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2023
Last Update Date: 07/10/2023
Certification Date: 07/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3360 W CACTUS AVE STE 150
LAS VEGAS NV
89141-8810
US

IV. Provider business mailing address

2030 OLYMPIC AVE APT 3123
HENDERSON NV
89014-2286
US

V. Phone/Fax

Practice location:
  • Phone: 702-527-1777
  • Fax:
Mailing address:
  • Phone: 215-268-8825
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number7874
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: